Provider Demographics
NPI:1629428099
Name:KLOTZ, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KLOTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4674 SNOW MESA DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8614
Mailing Address - Country:US
Mailing Address - Phone:970-266-3650
Mailing Address - Fax:970-266-3660
Practice Address - Street 1:4674 SNOW MESA DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-8614
Practice Address - Country:US
Practice Address - Phone:970-266-3650
Practice Address - Fax:970-266-3660
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.069264207R00000X, 208000000X
CODR.0064144208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000181978Medicaid