Provider Demographics
NPI:1083052872
Name:SVANCARA, KEVIN LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
Last Name:SVANCARA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2620 N 140TH AVE # 103
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2437
Mailing Address - Country:US
Mailing Address - Phone:623-219-4777
Mailing Address - Fax:623-219-4778
Practice Address - Street 1:2620 N 140TH AVE # 103
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2437
Practice Address - Country:US
Practice Address - Phone:623-219-4777
Practice Address - Fax:623-219-4778
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG163096207NI0002X
AZ6549207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology