Provider Demographics
NPI:1578675245
Name:O'MARA, KEVIN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:O'MARA
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 1:7126 E OSBORN RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6310
Mailing Address - Country:US
Mailing Address - Phone:813-362-3230
Mailing Address - Fax:
Practice Address - Street 1:1500 S MILL AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-6699
Practice Address - Country:US
Practice Address - Phone:480-784-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081691207P00000X
FLME97390207P00000X
CAA93623207P00000X
PAMD439347207P00000X
AZ45538207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2353484Medicaid
OH2353484Medicaid