Provider Demographics
NPI:1134130925
Name:KORNBLUTH, CRAIG M (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:M
Last Name:KORNBLUTH
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 1:1746 COLE BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3208
Mailing Address - Country:US
Mailing Address - Phone:303-914-8800
Mailing Address - Fax:303-716-3777
Practice Address - Street 1:1746 COLE BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3208
Practice Address - Country:US
Practice Address - Phone:303-914-8800
Practice Address - Fax:303-716-3777
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO414802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54988063Medicaid
COC801369Medicare PIN
COC803975Medicare PIN
COC801370Medicare PIN
CO54988063Medicaid
COP00192209Medicare PIN
COCOAAA0283Medicare PIN
COH66588Medicare UPIN
COC804000Medicare PIN
COC534238Medicare PIN