Provider Demographics
NPI:1821018953
Name:CONNOR, KEVIN JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:CONNOR
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 1:100 E CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-1703
Mailing Address - Country:US
Mailing Address - Phone:610-521-3333
Mailing Address - Fax:610-521-2263
Practice Address - Street 1:100 E CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-1703
Practice Address - Country:US
Practice Address - Phone:610-521-3333
Practice Address - Fax:610-521-2263
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010794L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA114038Medicaid
037391Medicare ID - Type Unspecified
PAH14460Medicare UPIN