Provider Demographics
NPI:1770668766
Name:MUTHERSBAUGH, KEVIN M (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:MUTHERSBAUGH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-4165
Mailing Address - Country:US
Mailing Address - Phone:203-333-7100
Mailing Address - Fax:203-333-0811
Practice Address - Street 1:1495 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-4165
Practice Address - Country:US
Practice Address - Phone:203-333-7100
Practice Address - Fax:203-333-0811
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001329111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT350001255Medicare PIN