Provider Demographics
NPI:1174622070
Name:BLAKE, KENNETH D (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8490 E CRESCENT PKWY STE 380
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2815
Mailing Address - Country:US
Mailing Address - Phone:303-957-1310
Mailing Address - Fax:303-761-4252
Practice Address - Street 1:10103 RIDGEGATE PKWY
Practice Address - Street 2:SUITE 208
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5520
Practice Address - Country:US
Practice Address - Phone:303-535-5350
Practice Address - Fax:303-535-5353
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41202208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04305876Medicaid
CO04305876Medicaid
CO804174Medicare PIN