Healthcare Provider Details

I. General information

NPI: 1689670655
Provider Name (Legal Business Name): KEITH KAPATKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 PRO RODEO DR STE 100
COLORADO SPRINGS CO
80919-2334
US

IV. Provider business mailing address

4190 E WOODMEN RD STE 100
COLORADO SPRINGS CO
80920-8075
US

V. Phone/Fax

Practice location:
  • Phone: 719-522-0707
  • Fax: 719-262-9495
Mailing address:
  • Phone: 719-632-4455
  • Fax: 719-633-4613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR.0061666
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD56380
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: