Provider Demographics
NPI:1083677231
Name:O'GORMAN, KEVIN N (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:N
Last Name:O'GORMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KEVIN
Other - Middle Name:N
Other - Last Name:O'GORMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8600 DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14057-1343
Mailing Address - Country:US
Mailing Address - Phone:716-992-4999
Mailing Address - Fax:716-992-9132
Practice Address - Street 1:8600 DEPOT ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NY
Practice Address - Zip Code:14057-1343
Practice Address - Country:US
Practice Address - Phone:716-992-4999
Practice Address - Fax:716-992-9132
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140567-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010352901OtherUNIVERA HEALTHCARE
NY00699409Medicaid
NY0401559OtherINDEPENDENT HEALTH
NY000508426001OtherBC/BS OF WNY
NYB71708Medicare UPIN
NY00699409Medicaid