Provider Demographics
NPI:1083608970
Name:KANE, KEVIN J (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:KANE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10340 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266
Mailing Address - Country:US
Mailing Address - Phone:503-232-1000
Mailing Address - Fax:503-232-1143
Practice Address - Street 1:10340 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266
Practice Address - Country:US
Practice Address - Phone:503-232-1000
Practice Address - Fax:503-232-1143
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO20375204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3555836Medicaid
OR06701800OtherBCBSO
OR3555836Medicaid