Provider Demographics
NPI:1568465656
Name:LAVERDURE, KELLY M (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:LAVERDURE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:KIERNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 8500-8567
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-8567
Mailing Address - Country:US
Mailing Address - Phone:609-815-7887
Mailing Address - Fax:215-860-7754
Practice Address - Street 1:750 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:19178-8567
Practice Address - Country:US
Practice Address - Phone:609-815-7810
Practice Address - Fax:609-815-7814
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011991960001Medicaid
PA086997Medicare PIN
PA086997P97Medicare PIN
PA1011991960001Medicaid