Provider Demographics
NPI:1689670655
Name:KAPATKIN, KEITH (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:KAPATKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 E WOODMEN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-8075
Mailing Address - Country:US
Mailing Address - Phone:719-632-4455
Mailing Address - Fax:719-633-4613
Practice Address - Street 1:104 PRO RODEO DR STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2334
Practice Address - Country:US
Practice Address - Phone:719-522-0707
Practice Address - Fax:719-262-9495
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD56380207RN0300X
CODR.0061666207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067672100Medicaid
FLD54073Medicare UPIN
FL30641ZMedicare ID - Type Unspecified