Provider Demographics
NPI:1720200744
Name:EGGLESTON, KEVIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:EGGLESTON
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 1:4619 KANAWHA AVE., SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309
Mailing Address - Country:US
Mailing Address - Phone:304-400-4545
Mailing Address - Fax:304-400-4546
Practice Address - Street 1:4619 KANAWHA AVE., SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309
Practice Address - Country:US
Practice Address - Phone:304-400-4545
Practice Address - Fax:304-400-4546
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21056207RP1001X, 207RS0012X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7617007Medicaid
WV3810009299Medicaid
NC7617007Medicaid