Provider Demographics
NPI:1578736724
Name:BELASCO, KEVIN TATE (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TATE
Last Name:BELASCO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SUPERIOR AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3606
Mailing Address - Country:US
Mailing Address - Phone:949-640-7546
Mailing Address - Fax:949-640-7547
Practice Address - Street 1:1501 SUPERIOR AVE STE 115
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3606
Practice Address - Country:US
Practice Address - Phone:949-640-7546
Practice Address - Fax:949-640-7547
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51343021207N00000X
CA20A12076207N00000X
NVDO1741207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI001417140OtherMEDICARE
WIP00690402OtherRAILROAD MEDICARE
WI51343-021OtherSTATE LICENSE
WI1578736724Medicaid
WI1578736724Medicaid
WIFB0753029OtherDEA
WI001417140OtherMEDICARE
CAFW320ZMedicare PIN