Healthcare Provider Details

I. General information

NPI: 1710910831
Provider Name (Legal Business Name): KELLY JEAN CUSHING D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 ARAPAHOE AVE
BOULDER CO
80303-1133
US

IV. Provider business mailing address

PO BOX 9049
BOULDER CO
80301-9049
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-7610
  • Fax: 303-415-7618
Mailing address:
  • Phone: 303-415-7610
  • Fax: 303-415-7618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDR.0056124
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO27740
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberDR.0056124
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0056124
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: