Provider Demographics
NPI:1316032584
Name:KEIDAN, BENJAMIN J (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:KEIDAN
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 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-4250
Mailing Address - Fax:303-440-9629
Practice Address - Street 1:5495 ARAPAHOE AVE STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1224
Practice Address - Country:US
Practice Address - Phone:303-415-4250
Practice Address - Fax:303-440-9629
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0043558207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88202241Medicaid
COP00402604OtherMEDICARE RAILROAD
COP00402604OtherMEDICARE RAILROAD
COC807495Medicare PIN