Healthcare Provider Details

I. General information

NPI: 1790978393
Provider Name (Legal Business Name): KALLGREN DERMATOLOGY CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 47TH ST #200
BOULDER CO
80301-1880
US

IV. Provider business mailing address

3434 47TH ST #200
BOULDER CO
80301-1880
US

V. Phone/Fax

Practice location:
  • Phone: 303-444-8100
  • Fax: 303-444-8113
Mailing address:
  • Phone: 303-444-8100
  • Fax: 303-444-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number33197
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number33197
License Number StateCO

VIII. Authorized Official

Name: MR. KEVIN MAGUIRE
Title or Position: OFFICE MANAGER
Credential:
Phone: 303-444-8100