Provider Demographics
NPI:1417243254
Name:MARTHALLER, KYLE JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JORDAN
Last Name:MARTHALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-443-2123
Mailing Address - Fax:303-443-9497
Practice Address - Street 1:4743 ARAPAHOE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1113
Practice Address - Country:US
Practice Address - Phone:303-443-2123
Practice Address - Fax:303-443-9497
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056793208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery