Provider Demographics
NPI:1619055340
Name:VANDERVEEN, KEVIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:VANDERVEEN
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 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:1375 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1114
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77861207P00000X
CO47483207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A778610Medicaid
CO020129OtherKAISER COMMERCIAL NUMBER
CO56486731Medicaid
CO56486731Medicaid
H96327Medicare UPIN
CA00A778610Medicaid
CA00A778610Medicaid