Provider Demographics
NPI:1164494241
Name:MAHONEY, KEVIN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ROBERT
Last Name:MAHONEY
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 1:120 N C AVE
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2410
Mailing Address - Country:US
Mailing Address - Phone:307-864-5534
Mailing Address - Fax:307-864-9470
Practice Address - Street 1:120 N C AVE
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2410
Practice Address - Country:US
Practice Address - Phone:307-864-5534
Practice Address - Fax:307-864-9470
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5591AWY207Q00000X
WY5591A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110846800Medicaid
WY512KRM98OtherWY CONTROLLED SUBSTANCE #
WY5591AWYOtherWY MEDICAL LICENSE #
WY5591AWYOtherWY MEDICAL LICENSE #
WYBM4697681OtherDEA
WYW10181Medicare ID - Type Unspecified
WY110846800Medicaid