Provider Demographics
NPI:1184662272
Name:VIDLOCK GRANLEY, KATHRYN A (MD)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:A
Last Name:VIDLOCK GRANLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:KATHRYN
Other - Middle Name:A
Other - Last Name:VIDLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:12760 STROH RANCH WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-7507
Mailing Address - Country:US
Mailing Address - Phone:720-851-5420
Mailing Address - Fax:720-851-5801
Practice Address - Street 1:12760 STROH RANCH WAY STE 202
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-7507
Practice Address - Country:US
Practice Address - Phone:720-851-5420
Practice Address - Fax:720-851-5801
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO52345207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG84388Medicare UPIN