Healthcare Provider Details

I. General information

NPI: 1457317703
Provider Name (Legal Business Name): SAMUEL J KEVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MEEKER ST
DELTA CO
81416-1920
US

IV. Provider business mailing address

555 MEEKER ST
DELTA CO
81416-1920
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-5777
  • Fax:
Mailing address:
  • Phone: 970-874-5777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23990
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: