Provider Demographics
NPI:1770684409
Name:DANYLCHUK, KENNETH D (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:DANYLCHUK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 E SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2209
Mailing Address - Country:US
Mailing Address - Phone:719-296-9000
Mailing Address - Fax:719-296-9001
Practice Address - Street 1:3530 E SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2209
Practice Address - Country:US
Practice Address - Phone:719-296-9000
Practice Address - Fax:719-296-9001
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29760174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01297605Medicaid
CO382618Medicare ID - Type Unspecified
COE48256Medicare UPIN