Provider Demographics
NPI:1922633171
Name:LAMAR, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LAMAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 OLD BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2607
Mailing Address - Country:US
Mailing Address - Phone:202-647-0304
Mailing Address - Fax:
Practice Address - Street 1:6431 OLD BRANCH AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2607
Practice Address - Country:US
Practice Address - Phone:202-647-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC042050500Medicaid