Provider Demographics
NPI:1982718441
Name:KONST-SKWIOT, KELLI JO (MD)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:JO
Last Name:KONST-SKWIOT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:JO
Other - Last Name:KONST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1830 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4275
Mailing Address - Country:US
Mailing Address - Phone:970-945-8503
Mailing Address - Fax:970-945-0253
Practice Address - Street 1:1905 BLAKE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4288
Practice Address - Country:US
Practice Address - Phone:970-945-2840
Practice Address - Fax:970-945-2893
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH93770207Q00000X
CO48893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71878769Medicaid
CO71878769Medicaid
CO101555Medicare PIN