Provider Demographics
NPI:1093946287
Name:MCCARTHY, KEVIN
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:MCCARTHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93407-0210
Mailing Address - Country:US
Mailing Address - Phone:805-756-1211
Mailing Address - Fax:
Practice Address - Street 1:1 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93407-0210
Practice Address - Country:US
Practice Address - Phone:805-756-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10993208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA10993OtherSTATE LICENSE
CAMM1951323OtherDEA