Provider Demographics
NPI:1578538690
Name:TRAYNOR, KEVIN MICHEAL (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHEAL
Last Name:TRAYNOR
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 1:2697 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2848
Mailing Address - Country:US
Mailing Address - Phone:772-335-0505
Mailing Address - Fax:772-335-0508
Practice Address - Street 1:2697 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2848
Practice Address - Country:US
Practice Address - Phone:772-335-0505
Practice Address - Fax:772-335-0508
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43541174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD20717Medicare UPIN
FL02194Medicare ID - Type Unspecified