Provider Demographics
NPI:1255492104
Name:MANDAGERE, KELLY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:MANDAGERE
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 1:892 W SOUTH BOULDER RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-2453
Mailing Address - Country:US
Mailing Address - Phone:303-586-5200
Mailing Address - Fax:303-586-5201
Practice Address - Street 1:892 W SOUTH BOULDER RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-2453
Practice Address - Country:US
Practice Address - Phone:303-586-5200
Practice Address - Fax:303-586-5201
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45001207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01159305Medicaid
CO81287895Medicaid
CO81287895Medicaid
CO01159305Medicaid