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NPI Code Detail

MEDICARE: DERIK K KENWORTHY DO

MEDICARE: DERIK K KENWORTHY DO
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
12085R0202XDiagnostic Radiology Physician05-50096KS
22085R0202XDiagnostic Radiology PhysicianOS21657FL
32085R0202XDiagnostic Radiology PhysicianMED-PHYS-LIC-148473MT
42085R0202XDiagnostic Radiology PhysicianV3891TX
52085R0202XDiagnostic Radiology PhysicianDR.0074105CO
62085R0202XDiagnostic Radiology Physician14225604-1204UT
72085R0202XDiagnostic Radiology PhysicianDO220167OR

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1Z173125OTHERMEDICARE PTAN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1861726077
Entity Type Code : Individual
Provider Name (Legal Business Name) : DERIK K KENWORTHY DO
Provider Business Mailing Address
First Line : 3600 MINNESOTA DR STE 800
Second Line :
City : EDINA
State : MN
Zip : 55435-7915
Country : US
Telephone Number : 952-595-1100
Fax Number : 612-294-4903
Provider Business Practice Location Address
First Line : 3600 MINNESOTA DR STE 800
Second Line :
City : EDINA
State : MN
Zip : 55435-7915
Country : US
Telephone Number : 952-595-1100
Fax Number : 612-294-4903
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/22/2009
Last Update Date : 03/09/2026

Similar Medicare Providers

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Practice Location Address:
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EDINA, MN
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1396761748 — KEVIN M CAWLEY MD
Practice Location Address:
3600 MINNESOTA DR STE 800
EDINA, MN
55435-7915
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Practice Fax: 612-294-4903
1104130269 — DR. ETHEL SUSAN HERSKOVIC DO
Practice Location Address:
3600 MINNESOTA DR STE 800
EDINA, MN
55435-7915
Practice Phone: 952-595-1100
Practice Fax: 612-294-4903
1710354352 — GABRIELA A. SANTOS NUNEZ MD
Practice Location Address:
3600 MINNESOTA DR STE 800
EDINA, MN
55435-7915
Practice Phone: 952-595-1100
Practice Fax: 612-294-4903

Directions to “ DERIK K KENWORTHY DO” Practice Location

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