Provider Demographics
NPI:1629042023
Name:MICETICH, KARA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:LYNN
Last Name:MICETICH
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 1:2457 IOWA DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4709
Mailing Address - Country:US
Mailing Address - Phone:970-481-4435
Mailing Address - Fax:
Practice Address - Street 1:2457 IOWA DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4709
Practice Address - Country:US
Practice Address - Phone:970-481-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36904207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01369040Medicaid
84059624515OtherPACIFICARE
MI84128OtherBCBS
CO01369040Medicaid
COC84128Medicare PIN