Provider Demographics
NPI:1134272602
Name:KIMATA, GLENN TETSUO (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:TETSUO
Last Name:KIMATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8771 WOLFF CT
Mailing Address - Street 2:SUITE 115
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-6948
Mailing Address - Country:US
Mailing Address - Phone:303-650-8005
Mailing Address - Fax:303-412-5891
Practice Address - Street 1:8771 WOLFF CT
Practice Address - Street 2:SUITE 115
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-6948
Practice Address - Country:US
Practice Address - Phone:303-650-8005
Practice Address - Fax:303-412-5891
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO242392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
186554300OtherOWCP
073386OtherVALUE OPTIONS
32557OtherFEDERAL BLUE CROSS & BLUE
32557OtherFEDERAL BLUE CROSS & BLUE
COC801068Medicare PIN