Provider Demographics
NPI:1952373722
Name:DERNOVSEK, KENNETH D (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:DERNOVSEK
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 1:1925 E ORMAN AVE
Mailing Address - Street 2:STE 115
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3537
Mailing Address - Country:US
Mailing Address - Phone:719-564-4500
Mailing Address - Fax:719-564-0304
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:STE 115
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-564-4500
Practice Address - Fax:719-564-0304
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26083207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO460003468OtherRAILROAD MEDICARE
CO01260835Medicaid
CO1952373722OtherRAILROAD MEDICARE
D24748Medicare UPIN
CO01260835Medicaid