Provider Demographics
NPI:1710985973
Name:THAYER, KENT H JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:H
Last Name:THAYER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:124 MAYHURST AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3056
Mailing Address - Country:US
Mailing Address - Phone:719-577-9655
Mailing Address - Fax:
Practice Address - Street 1:75 PRINTERS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3151
Practice Address - Country:US
Practice Address - Phone:719-634-1994
Practice Address - Fax:719-634-2906
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18431208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01184316Medicaid
CO7248Medicare ID - Type Unspecified
CO01184316Medicaid