Provider Demographics
NPI:1134492739
Name:G KENNETH DEAGMAN MD PC
Entity Type:Organization
Organization Name:G KENNETH DEAGMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:K
Authorized Official - Last Name:DEAGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-755-1164
Mailing Address - Street 1:1550 S POTOMAC ST
Mailing Address - Street 2:360
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-5457
Mailing Address - Country:US
Mailing Address - Phone:303-755-1164
Mailing Address - Fax:303-755-1147
Practice Address - Street 1:1550 S POTOMAC ST
Practice Address - Street 2:360
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5457
Practice Address - Country:US
Practice Address - Phone:303-755-1164
Practice Address - Fax:303-755-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE04756Medicare UPIN