Provider Demographics
NPI:1679539803
Name:STAVELEY-OCARROLL, KEVIN F (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:F
Last Name:STAVELEY-OCARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8063
Mailing Address - Country:US
Mailing Address - Phone:860-679-8080
Mailing Address - Fax:860-679-1340
Practice Address - Street 1:263 FARMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-8063
Practice Address - Country:US
Practice Address - Phone:860-679-8080
Practice Address - Fax:860-679-1340
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT076526208600000X
PAMD071461L208600000X
MO2015030565208600000X, 2086X0206X
SC355582086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018125830001Medicaid
F62639Medicare UPIN
PA0018125830001Medicaid