Provider Demographics
NPI:1154325520
Name:SAND, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:SAND
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 1:2597 QUARRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-7659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:563-382-9671
Practice Address - Fax:563-382-5015
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1164343Medicaid
IA49785Medicare ID - Type Unspecified
A01476Medicare UPIN