MEDICARE: DR. KEVIN MATTHEW DERICKSON D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213EP1101X	Primary Podiatric Medicine Podiatrist	PO2824	FL
2	213EP1101X	Primary Podiatric Medicine Podiatrist	POD.0000548	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396748497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN MATTHEW DERICKSON D.P.M.

Provider Business Mailing Address
First Line	:	PO BOX 21150
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80308-4150
Country	:	US
Telephone Number	:	33-551-6953
Fax Number	:	303-355-1834

Provider Business Practice Location Address
First Line	:	2121 S ONEIDA ST STE 270
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80224-2551
Country	:	US
Telephone Number	:	303-355-1695
Fax Number	:	303-355-1834

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	11/04/2022

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Directions to “ DR. KEVIN MATTHEW DERICKSON D.P.M.” Practice Location

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