Provider Demographics
NPI:1144214016
Name:KALLGREN, DIANE LUCY (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LUCY
Last Name:KALLGREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 47TH ST
Mailing Address - Street 2:#200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1880
Mailing Address - Country:US
Mailing Address - Phone:303-444-8100
Mailing Address - Fax:303-444-8113
Practice Address - Street 1:3434 47TH ST
Practice Address - Street 2:#200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1880
Practice Address - Country:US
Practice Address - Phone:303-444-8100
Practice Address - Fax:303-444-8113
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33197174400000X, 207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF76653Medicare UPIN
CO804659Medicare PIN