Provider Demographics
NPI:1487619532
Name:SEAQUIST, DEREK KEVIN (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:KEVIN
Last Name:SEAQUIST
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:PO BOX 744127
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-4127
Mailing Address - Country:US
Mailing Address - Phone:719-776-5816
Mailing Address - Fax:
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6819
Practice Address - Country:US
Practice Address - Phone:719-776-5816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22764207ZP0102X
CO0056992207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000146429Medicaid