Healthcare Provider Details

I. General information

NPI: 1386226991
Provider Name (Legal Business Name): BRIAN THOMAS KETTERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9094 E. MINERAL AVE. #100
CENTENNIAL CO
80112
US

IV. Provider business mailing address

9094 E. MINERAL AVE. #100
CENTENNIAL CO
80112
US

V. Phone/Fax

Practice location:
  • Phone: 303-694-3200
  • Fax:
Mailing address:
  • Phone: 303-694-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0072575
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: