Provider Demographics
NPI:1003867771
Name:O'BRIEN, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:O'BRIEN
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 1:2413 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1637
Mailing Address - Country:US
Mailing Address - Phone:574-732-4609
Mailing Address - Fax:574-732-1049
Practice Address - Street 1:2413 HIGH ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1637
Practice Address - Country:US
Practice Address - Phone:574-732-4609
Practice Address - Fax:574-732-1049
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100070980Medicaid
IN100070980Medicaid
IN090540XMedicare ID - Type Unspecified