Provider Demographics
NPI:1841215480
Name:DEAN, KEVIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:DEAN
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 1:1601 CUMMINS DR
Mailing Address - Street 2:STE D
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-6411
Mailing Address - Country:US
Mailing Address - Phone:888-828-3196
Mailing Address - Fax:
Practice Address - Street 1:10123 SE MARKET ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2532
Practice Address - Country:US
Practice Address - Phone:503-252-2004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91503207P00000X
WAMD61248946207P00000X
ORMD26601207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
858543032OtherREGENCE BCBS
OR005942Medicaid
CAXPY206686Medicaid
WA8460289Medicaid
210867OtherWA L & I
8942007OtherWA CRIME VICTIMS
P00377905OtherRAILROAD MEDICARE
8942007OtherWA CRIME VICTIMS
210867OtherWA L & I