Provider Demographics
NPI:1689674202
Name:KELLEHER, KEVIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:KELLEHER
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 1:12040 S LAKES DR
Mailing Address - Street 2:STE 207
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1246
Mailing Address - Country:US
Mailing Address - Phone:703-464-0686
Mailing Address - Fax:703-464-0698
Practice Address - Street 1:12040 S LAKES DR
Practice Address - Street 2:STE 207
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1246
Practice Address - Country:US
Practice Address - Phone:703-464-0686
Practice Address - Fax:703-464-0698
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG00463OtherMEDICARE GROUP
VA542011791OtherTIN
VAG35598Medicare UPIN
00A088G63Medicare PIN
VA542011791OtherTIN