Provider Demographics
NPI:1629070032
Name:HART, KEVIN K (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:HART
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2022-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039466A207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN060070578OtherRR MEDICARE
OH2058455Medicaid
IN200006660Medicaid
IN000000641084OtherANTHEM
INP00782373OtherR.R. MEDICARE
INE94288Medicare UPIN
IN193590HMedicare PIN
IN060070578OtherRR MEDICARE
IN193580HMedicare PIN
OH2058455Medicaid