Provider Demographics
NPI:1508431107
Name:NYABERA, KEVIN OTUNDO (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:OTUNDO
Last Name:NYABERA
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 1:504 HOPE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-6767
Mailing Address - Country:US
Mailing Address - Phone:919-637-3524
Mailing Address - Fax:
Practice Address - Street 1:39200 HOOKER HWY
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-5368
Practice Address - Country:US
Practice Address - Phone:561-996-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL33001207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty