Provider Demographics
NPI:1962558544
Name:WANEBO, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WANEBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 GRAPE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-4431
Mailing Address - Country:US
Mailing Address - Phone:303-333-8174
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF COLORADO AT DENVER AND HEALTH SCIENCES CE
Practice Address - Street 2:4200 E. 9TH AVE.
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80262-0001
Practice Address - Country:US
Practice Address - Phone:720-848-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO455712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology