Provider Demographics
NPI:1639604515
Name:ITTY, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:ITTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 NW 13TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2269
Mailing Address - Country:US
Mailing Address - Phone:561-292-4949
Mailing Address - Fax:561-292-4612
Practice Address - Street 1:2815 S SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7969
Practice Address - Country:US
Practice Address - Phone:561-292-4949
Practice Address - Fax:561-292-4612
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56750207R00000X
FLME145022207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine