Provider Demographics
NPI:1346394152
Name:KUTALEK, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:KUTALEK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:30960 STAGECOACH BLVD
Mailing Address - Street 2:SUITE W120
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7902
Mailing Address - Country:US
Mailing Address - Phone:303-674-6671
Mailing Address - Fax:303-674-0031
Practice Address - Street 1:30960 STAGECOACH BLVD
Practice Address - Street 2:SUITE W120
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7902
Practice Address - Country:US
Practice Address - Phone:303-674-6671
Practice Address - Fax:303-674-0031
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO26133208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01261338Medicaid