Provider Demographics
NPI:1376546002
Name:LOCKE, KELLY TAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:TAY
Last Name:LOCKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:401 CASTLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1159
Mailing Address - Country:US
Mailing Address - Phone:970-279-4111
Mailing Address - Fax:970-927-3915
Practice Address - Street 1:401 CASTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-1159
Practice Address - Country:US
Practice Address - Phone:970-279-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK210985207Q00000X
CO38023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
549098Medicare ID - Type Unspecified
COF77369Medicare UPIN