Provider Demographics
NPI:1457317703
Name:KEVAN, SAMUEL J (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:KEVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MEEKER ST
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-1920
Mailing Address - Country:US
Mailing Address - Phone:970-874-5777
Mailing Address - Fax:
Practice Address - Street 1:555 MEEKER ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-1920
Practice Address - Country:US
Practice Address - Phone:970-874-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01239904Medicaid
C64122Medicare UPIN
CO01239904Medicaid