Provider Demographics
NPI:1801873963
Name:FOOTE, KATHLEEN S (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:S
Last Name:FOOTE
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:719-463-5600
Mailing Address - Fax:
Practice Address - Street 1:15909 JACKSON CREEK PKWY
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-8693
Practice Address - Country:US
Practice Address - Phone:719-488-6998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0037997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16459831Medicaid
CO16459831Medicaid
COH39058Medicare UPIN