Healthcare Provider Details

I. General information

NPI: 1669761995
Provider Name (Legal Business Name): KAITLIN DOROTHY VELLORE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4803 WARD RD
WHEAT RIDGE CO
80033-1902
US

IV. Provider business mailing address

10350 E DAKOTA AVE
DENVER CO
80247-1314
US

V. Phone/Fax

Practice location:
  • Phone: 303-338-4545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME118499
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0055171
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier026514
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerKAISER COMMERCIAL NUMBER
# 2
Identifier40783260
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 3
Identifier010552600
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: