Provider Demographics
NPI:1811090103
Name:ADNAN, KENDRICK MCDONALD (MD)
Entity type:Individual
Prefix:DR
First Name:KENDRICK
Middle Name:MCDONALD
Last Name:ADNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27 MAIN ST # C301
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-8109
Mailing Address - Country:US
Mailing Address - Phone:970-569-3600
Mailing Address - Fax:970-569-3601
Practice Address - Street 1:555 SOUTH PARK
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424
Practice Address - Country:US
Practice Address - Phone:970-453-1010
Practice Address - Fax:970-453-5407
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32659207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1326594Medicaid
F70941Medicare UPIN
CO397318Medicare ID - Type UnspecifiedBRECKENRIDGE MED CTR