Provider Demographics
NPI:1871665257
Name:HEACOCK, KEVIN FLOYD (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:FLOYD
Last Name:HEACOCK
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 1:2510 FIFTH ST., BLDG 840
Mailing Address - Street 2:RM W106D
Mailing Address - City:WRIGHT-PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-7913
Mailing Address - Country:US
Mailing Address - Phone:937-938-2702
Mailing Address - Fax:
Practice Address - Street 1:2510 FIFTH ST., BLDG 840
Practice Address - Street 2:RM W106D
Practice Address - City:WRIGHT-PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-7913
Practice Address - Country:US
Practice Address - Phone:937-938-2702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD65268207R00000X
NE259512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine