Basic Information
| Provider Information | |||||||||
| NPI: | 1417983891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAILASAM | ||||||||
| FirstName: | VELUSAMY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 603725 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282603725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502163 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702212370 | ||||||||
| FaxNumber: | 9702219654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 27171 | CO | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 391636ZMHC | 01 | CO | MEDICARE PTAN | OTHER | W27259 | 01 | WY | MEDICARE PTAN | OTHER | 01271717 | 05 | CO | MEDICAID |