Provider Demographics
NPI:1366400178
Name:MCCLINTOCK, KEVIN LEONARD (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEONARD
Last Name:MCCLINTOCK
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 1:801 WEST COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-1319
Mailing Address - Country:US
Mailing Address - Phone:719-846-3133
Mailing Address - Fax:
Practice Address - Street 1:1207 PUEBLO BOULEVARD WAY
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2175
Practice Address - Country:US
Practice Address - Phone:195-420-0327
Practice Address - Fax:719-542-1413
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35456207P00000X
CODR.0035456208M00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01354562Medicaid
CO01354562Medicaid
CO298735YXBWMedicare PIN