Provider Demographics
NPI:1730164708
Name:DELLOTA, KRISS LAWRENCE
Entity type:Individual
Prefix:
First Name:KRISS
Middle Name:LAWRENCE
Last Name:DELLOTA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KRISS
Other - Middle Name:L
Other - Last Name:DELLOTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 912215
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2215
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:
Practice Address - Street 1:1024 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3929
Practice Address - Country:US
Practice Address - Phone:970-495-8006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40586207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO27607861Medicaid
NE55827847Medicaid
S5008OtherBCBS
WY117530100Medicaid
S5008OtherBCBS
WY117530100Medicaid
C496178Medicare PIN