Provider Demographics
NPI:1376606392
Name:COATES, KENNETH N (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:N
Last Name:COATES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 N UNION BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2810
Mailing Address - Country:US
Mailing Address - Phone:719-632-7878
Mailing Address - Fax:719-632-2957
Practice Address - Street 1:1512 N UNION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2810
Practice Address - Country:US
Practice Address - Phone:719-632-7878
Practice Address - Fax:719-632-2957
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO393213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01003938Medicaid
C50753Medicare ID - Type Unspecified
CO01003938Medicaid
T60242Medicare UPIN