Provider Demographics
NPI:1578787735
Name:O'BRYAN, KEVIN W (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:O'BRYAN
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:501 S 2ND ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2862
Practice Address - Country:US
Practice Address - Phone:502-589-3429
Practice Address - Fax:502-583-7546
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256380207N00000X, 207ND0101X, 207NS0135X
KY48776207ND0101X, 207N00000X, 207NS0135X
IN01076508A207NS0135X, 207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology