Provider Demographics
NPI:1184776114
Name:CHISMIRE, KEVIN J (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:CHISMIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1800 E. PAVILION PLACE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401
Mailing Address - Country:US
Mailing Address - Phone:970-249-1210
Mailing Address - Fax:970-249-3057
Practice Address - Street 1:1800 E. PAVILION PLACE
Practice Address - Street 2:SUITE B
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401
Practice Address - Country:US
Practice Address - Phone:970-249-1210
Practice Address - Fax:970-249-3057
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO27759207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54774845Medicaid
P00094915OtherRAILROAD MEDICARE
667552OtherBLUECROSS BLUESHIELD
840851676006OtherROCKY MOUNTAIN HEALTH PLA
CO54774845Medicaid
C517358Medicare PIN