Provider Demographics
NPI:1497727184
Name:QUACKENBUSH, KIRK T (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:T
Last Name:QUACKENBUSH
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 1:550 S WADSWORTH BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-3111
Mailing Address - Country:US
Mailing Address - Phone:303-202-1283
Mailing Address - Fax:303-202-1281
Practice Address - Street 1:1600 PRAIRIE CENTER PKWY
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-4006
Practice Address - Country:US
Practice Address - Phone:303-458-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26543207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01265438Medicaid
CO930098610OtherRR MEDICARE
CO930098610OtherRR MEDICARE
COC366058Medicare PIN