Healthcare Provider Details

I. General information

NPI: 1619362084
Provider Name (Legal Business Name): BLAKE KANDAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S POTOMAC ST STE 150
AURORA CO
80012-4541
US

IV. Provider business mailing address

1400 S POTOMAC ST STE 150
AURORA CO
80012-4541
US

V. Phone/Fax

Practice location:
  • Phone: 720-476-3421
  • Fax: 720-502-5271
Mailing address:
  • Phone: 720-307-7246
  • Fax: 720-502-5271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD192439
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberDR.0065176
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: