Basic Information
| Provider Information | |||||||||
| NPI: | 1841289766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KALEVIK | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035349550 | ||||||||
| FaxNumber: | 7209327805 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 WAZEE ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802021478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035349550 | ||||||||
| FaxNumber: | 7209327805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 04/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32024 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05689376 | 05 | CO | MEDICAID |