Healthcare Provider Details

I. General information

NPI: 1104938208
Provider Name (Legal Business Name): TODD LANE KOOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 E GEDDES AVE STE 300
ENGLEWOOD CO
80112-3895
US

IV. Provider business mailing address

10800 E GEDDES AVE STE 300
ENGLEWOOD CO
80112-3895
US

V. Phone/Fax

Practice location:
  • Phone: 303-761-9190
  • Fax: 720-874-4462
Mailing address:
  • Phone: 303-761-9190
  • Fax: 720-874-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26523
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number04-36314
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number50665
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD17508
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD00046721
License Number StateWA
# 6
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberDR.0050665
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: