Provider Demographics
NPI:1598965212
Name:ICKES, KRISTEN ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:ICKES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40000
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81658-7520
Mailing Address - Country:US
Mailing Address - Phone:970-476-2451
Mailing Address - Fax:
Practice Address - Street 1:1835 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1126
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49949207R00000X
VA0116019715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO022032OtherKAISER COMMERCIAL NUMBER
CO22650253Medicaid
CO022032OtherKAISER COMMERCIAL NUMBER