Provider Demographics
NPI:1689640633
Name:FLYNN, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:FLYNN
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 1:12201 RENFERT WAY STE 305
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5371
Mailing Address - Country:US
Mailing Address - Phone:512-279-3376
Mailing Address - Fax:512-666-3244
Practice Address - Street 1:12201 RENFERT WAY STE 305
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5371
Practice Address - Country:US
Practice Address - Phone:512-279-3376
Practice Address - Fax:512-540-8524
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1011207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X, 207ZP0102X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8M7134OtherBCBS OF TEXAS INDIVIDUAL #
TX8B2644OtherBCBSTX
TX8M7134OtherBCBS OF TEXAS INDIVIDUAL #
8L4520Medicare PIN
TX8J0588Medicare PIN
TX00440ZMedicare PIN