Provider Demographics
NPI:1013973668
Name:SENN, KEVIN MARK (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MARK
Last Name:SENN
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 1:707 SW GAINES ST.
Mailing Address - Street 2:CDRC
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3098
Mailing Address - Country:US
Mailing Address - Phone:503-494-1619
Mailing Address - Fax:503-494-6868
Practice Address - Street 1:707 SW GAINES ST.
Practice Address - Street 2:CDRC
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-494-1619
Practice Address - Fax:503-494-6868
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183438208000000X, 2080P0008X
OR1533122080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY183438OtherLICENSE
040426000235OtherFIDELIS
PA0018547990001Medicaid
NY01402900Medicaid
00010162101OtherUNIVERA
000511836003OtherBC/BS
040426000240OtherFIDELIS
1205731OtherIHA
F66694Medicare UPIN
NY01402900Medicaid