Provider Demographics
NPI:1639117047
Name:KEVORKIAN, CONSTANCE M (MD)
Entity Type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:M
Last Name:KEVORKIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 KEMPSVILLE RD
Mailing Address - Street 2:BUILDING B
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4700
Mailing Address - Country:US
Mailing Address - Phone:757-668-6500
Mailing Address - Fax:
Practice Address - Street 1:171 KEMPSVILLE RD
Practice Address - Street 2:BUILDING B
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4700
Practice Address - Country:US
Practice Address - Phone:757-668-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034274208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
006700861OtherVA PREMIER
541778786001OtherTRICARE
233007OtherMDIPA/MAMSI
330031OtherANTHEM
NC890610QMedicaid
13609OtherOPTIMA
006700861OtherVA PREMIER
NC890610QMedicaid