Provider Demographics
NPI:1396748497
Name:DERICKSON, KEVIN MATTHEW (DPM)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MATTHEW
Last Name:DERICKSON
Suffix:
Gender:M
Credentials:DPM
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 21150
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-4150
Mailing Address - Country:US
Mailing Address - Phone:033-551-6953
Mailing Address - Fax:303-355-1834
Practice Address - Street 1:2121 S ONEIDA ST STE 270
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-2551
Practice Address - Country:US
Practice Address - Phone:303-355-1695
Practice Address - Fax:303-355-1834
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2824213EP1101X
COPOD.0000548213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000901249CMedicaid
FL65635OtherBCBS PROVIDER NUMBER
FL99039OtherGROUP BCBS ID
FLP00625824OtherMEDICARE RAIL ROAD
FL340058100Medicaid
FL340058100Medicaid
FL65635OtherBCBS PROVIDER NUMBER
FLU76655Medicare UPIN
FL65635ZMedicare PIN