Provider Demographics
NPI:1760479042
Name:KENNY MOYNIHAN, MARY BERNADETTE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BERNADETTE
Last Name:KENNY MOYNIHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7444 W ALASKA DR
Mailing Address - Street 2:STE 250
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-3327
Mailing Address - Country:US
Mailing Address - Phone:303-592-7284
Mailing Address - Fax:303-892-0601
Practice Address - Street 1:7444 W ALASKA DR
Practice Address - Street 2:STE 250
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3327
Practice Address - Country:US
Practice Address - Phone:303-592-7284
Practice Address - Fax:303-892-0601
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO34459207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94287091Medicaid
COC66263Medicare PIN
CO463548Medicare PIN
F59738Medicare UPIN
COCP4008Medicare Oscar/Certification