Provider Demographics
NPI:1316093941
Name:RUNYAN, MATTHEW KIMBALL (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KIMBALL
Last Name:RUNYAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 WELLINGTON AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6129
Mailing Address - Country:US
Mailing Address - Phone:970-243-7245
Mailing Address - Fax:
Practice Address - Street 1:2635 N 7TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JCT
Practice Address - State:CO
Practice Address - Zip Code:81501-8209
Practice Address - Country:US
Practice Address - Phone:970-244-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46772207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36331236Medicaid
CO36331236Medicaid