Provider Demographics
NPI:1669479705
Name:BOHANON, KATHLEEN SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:SUE
Last Name:BOHANON
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 1:4090 STONEBRIDGE PT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-4704
Mailing Address - Country:US
Mailing Address - Phone:719-685-0585
Mailing Address - Fax:
Practice Address - Street 1:4090 STONEBRIDGE PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-4704
Practice Address - Country:US
Practice Address - Phone:719-685-0585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO385052080N0001X
OH35042157B2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92524354Medicaid
CO92524354Medicaid