Provider Demographics
NPI:1679512065
Name:STALEY, KEVIN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:STALEY
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3 SHIPWAY PL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-4301
Mailing Address - Country:US
Mailing Address - Phone:617-643-0363
Mailing Address - Fax:617-643-0141
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:WAC 708D
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-643-0363
Practice Address - Fax:617-643-0141
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2012-12-26
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Provider Licenses
StateLicense IDTaxonomies
MA2300112084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology