Provider Demographics
NPI:1659335396
Name:OCONNOR, KEVIN T (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:T
Last Name:OCONNOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 S GREENVILLE WEST DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-3514
Practice Address - Country:US
Practice Address - Phone:616-754-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010639208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3526975Medicaid
MI3162370Medicaid
MI3162370Medicaid
F86929Medicare UPIN
KO010639Medicare ID - Type Unspecified