Provider Demographics
NPI:1437154366
Name:BUNDY, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:BUNDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:303-415-8940
Mailing Address - Fax:303-425-9259
Practice Address - Street 1:1755 48TH ST STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2712
Practice Address - Country:US
Practice Address - Phone:303-415-7450
Practice Address - Fax:303-494-5265
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054687207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2186932Medicaid
OHP00847945OtherRAILROAD MEDICARE
OH202421Medicare PIN
OHH16977Medicare UPIN
OH2186932Medicaid