Provider Demographics
NPI:1649212572
Name:O'REILLY, KEVIN DEAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DEAN
Last Name:O'REILLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1556 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-4710
Mailing Address - Country:US
Mailing Address - Phone:909-885-0652
Mailing Address - Fax:909-885-5022
Practice Address - Street 1:1556 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-4710
Practice Address - Country:US
Practice Address - Phone:909-885-0652
Practice Address - Fax:909-885-5022
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3466213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5421119Medicaid
CA0630660001Medicare NSC
CA5421119Medicaid
CA000E34660Medicare PIN