Healthcare Provider Details

I. General information

NPI: 1316093941
Provider Name (Legal Business Name): MATTHEW KIMBALL RUNYAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 03/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 N 7TH ST
GRAND JCT CO
81501-8209
US

IV. Provider business mailing address

1120 WELLINGTON AVE SUITE 206
GRAND JUNCTION CO
81501-6129
US

V. Phone/Fax

Practice location:
  • Phone: 970-244-2273
  • Fax:
Mailing address:
  • Phone: 970-243-7245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number46772
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: