Provider Demographics
NPI:1780681080
Name:BAXTER, KEVIN J (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:BAXTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-0450
Mailing Address - Country:US
Mailing Address - Phone:503-741-3570
Mailing Address - Fax:503-741-3569
Practice Address - Street 1:10 PIER 1 STE 301
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-6338
Practice Address - Country:US
Practice Address - Phone:503-741-3570
Practice Address - Fax:503-741-3569
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO24314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227275Medicaid
ORDO24314OtherSTATE LICENSE
OR227275Medicaid
H43280Medicare UPIN
ORH43280Medicare UPIN
ORR116512Medicare PIN