Provider Demographics
NPI:1760147631
Name:O'DONNOGHUE, KEVIN MITCHELL (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MITCHELL
Last Name:O'DONNOGHUE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4358 SIMPERS DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21102-2348
Mailing Address - Country:US
Mailing Address - Phone:443-602-1087
Mailing Address - Fax:
Practice Address - Street 1:2564 RIVA RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7405
Practice Address - Country:US
Practice Address - Phone:210-266-6626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist