NPIMap

Individual provider Active NPI

Kenneth S Watanabe, M.D.

  • Psychiatry Physician
  • Fort Collins, CO
National Provider Identifier
1780792747
Registry record updated Mar 7, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
40296 Issued in CO
Practice address
4601 Corbett Dr
Fort Collins, CO 80528-9579
Phone
(970) 207-4800
Fax
(970) 207-4805
NPI assigned
Aug 29, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X 40296 CO Primary

Addresses

Primary practice location

4601 Corbett Dr
Fort Collins, CO 80528-9579

Mailing address

4601 Corbett Dr
Fort Collins, CO 80528-9579
Phone (970) 207-4800

Other identifiers 1

IdentifierTypeStateIssuer
47723066MedicaidCO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100329001172 CO Practitioner - Psychiatry 5799811782 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Psychiatry
Education
University of Virginia School of Medicine, 1993
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Poudre Valley Medical Group LLCGroup PAC ID 9638208549, 2,425 clinicians

Practice addresses (Care Compare)

1107 S Lemay Ave
Suite 100
Fort Collins, CO 80524-3956
Phone (970) 207-4857

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
40296COMDPsychiatry Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Poudre Valley Medical Group, LLC CurrentSince Sep 25, 2025 Accepting new patients
Poudre Valley Health Care Inc. Current Accepting new patients
Poudre Valley Medical Group, LLC Current Accepting new patients
Poudre Valley Health Care Inc CurrentSince Jul 1, 2002 Accepting new patients

Locations

4404 Barranca Ln
Castle Rock, CO 80104
Phone (720) 733-5260

1107 S Lemay Ave
Ste 100
Fort Collins, CO 80524
Phone (970) 207-4857

1025 Pennock Pl
Fort Collins, CO 80524
Phone (970) 495-8800

1025 Pennock Pl
#111
Fort Collins, CO 80524

4601 Corbett Dr
Fort Collins, CO 80528
Phone (970) 207-4800

2695 Rocky Mountain Ave
Ste 150
Loveland, CO 80538
Phone (970) 624-2403

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 19

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 19

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156809600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678147200000",
    "number": "1780792747",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4601 CORBETT DR",
            "city": "FORT COLLINS",
            "state": "CO",
            "postal_code": "805289579",
            "telephone_number": "970-207-4800",
            "fax_number": "970-207-4805"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4601 CORBETT DR",
            "city": "FORT COLLINS",
            "state": "CO",
            "postal_code": "805289579",
            "telephone_number": "970-207-4800",
            "fax_number": "970-207-4805"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WATANABE",
        "first_name": "KENNETH",
        "middle_name": "S",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-29",
        "last_updated": "2023-03-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "CO",
            "license": "40296",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "47723066",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Collins, CO

Sources for this page

Verify at the official NPI Registry.