Provider Demographics
NPI:1568545481
Name:O BRIEN, KEVIN JOHN (DPM)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:O BRIEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 N STOCKTON HILL RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4100
Mailing Address - Country:US
Mailing Address - Phone:928-854-4307
Mailing Address - Fax:928-854-4339
Practice Address - Street 1:2302 N STOCKTON HILL RD
Practice Address - Street 2:SUITE G
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4100
Practice Address - Country:US
Practice Address - Phone:928-854-4307
Practice Address - Fax:928-854-4339
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0541213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00156933OtherRAILROAD MEDICARE
AZ572124Medicaid
AZP00156933OtherRAILROAD MEDICARE
AZ5322090001Medicare NSC
AZZ78686Medicare PIN
B07406312OtherDEA