Provider Demographics
NPI:1942510383
Name:DUFENDACH, KEVIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:DUFENDACH
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 1:3333 BURNET AVE
Mailing Address - Street 2:ML 7009
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-803-4232
Mailing Address - Fax:513-636-4404
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 7009
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-803-4232
Practice Address - Fax:513-636-4404
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1289322080N0001X, 2080N0001X
TN505602080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN370004500Medicare PIN