Provider Demographics
NPI:1700862745
Name:HARTSHORN, KEVAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVAN
Middle Name:L
Last Name:HARTSHORN
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 1:720 HARRISON AVE
Mailing Address - Street 2:DOB-503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVE
Practice Address - Street 2:MOAKLEY, 3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6248
Practice Address - Fax:617-638-5756
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49999207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110064373AMedicaid
MAUX7084Medicare PIN
MAJ03299Medicare PIN
MA110064373AMedicaid