Provider Demographics
NPI:1265452817
Name:KINNICK, TODD ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ANTHONY
Last Name:KINNICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 WELLINGTON AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6131
Mailing Address - Country:US
Mailing Address - Phone:970-243-7245
Mailing Address - Fax:970-241-1308
Practice Address - Street 1:1120 WELLINGTON AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6129
Practice Address - Country:US
Practice Address - Phone:970-243-7245
Practice Address - Fax:970-241-1308
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0044198207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55230059Medicaid
P00366838OtherRAILROAD MEDICARE
UTT0514Medicaid
P00366838OtherRAILROAD MEDICARE