Provider Demographics
NPI:1487781431
Name:JEONG, KELLY C (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:JEONG
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 1:8175 SHERIDAN BLVD UNIT N
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80003-1928
Mailing Address - Country:US
Mailing Address - Phone:303-557-0855
Mailing Address - Fax:
Practice Address - Street 1:8175 SHERIDAN BLVD UNIT N
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80003-1928
Practice Address - Country:US
Practice Address - Phone:303-557-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0038762207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
012280OtherKAISER-COMMERCIAL NUMBER
CO83538526Medicaid
CO83538526Medicaid
COCK11009Medicare PIN