Provider Demographics
NPI:1730103292
Name:CORCORAN-KELLY, SUSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:CORCORAN-KELLY
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 1:308 TEAL CT
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-6108
Mailing Address - Country:US
Mailing Address - Phone:970-686-2086
Mailing Address - Fax:
Practice Address - Street 1:3519 RICHMOND DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-5995
Practice Address - Country:US
Practice Address - Phone:970-204-0300
Practice Address - Fax:970-226-9041
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43887207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1246657Medicaid
NYE77940Medicare UPIN
NY1246657Medicaid