Basic Information
| Provider Information | |||||||||
| NPI: | 1578683223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEZEOR | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 N ACADEMY BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702668822 | ||||||||
| FaxNumber: | 9702668833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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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 | 207Q00000X | DR.0053122 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD-45754 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 57589 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD22717 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 64736 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60913138 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 281-320 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 18414 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 11037807-1205 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 04-41643 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 11383 | SD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | CDRH.0053122 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 43600361 | 05 | CO | MEDICAID | 47081633613 | 05 | NE | MEDICAID | P01275583 | 01 | CO | MEDICARE RAILROAD | OTHER |