Provider Demographics
NPI:1184975427
Name:O'ROURKE, KEVIN RUSSELL
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RUSSELL
Last Name:O'ROURKE
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 1:4040 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2684
Mailing Address - Country:US
Mailing Address - Phone:619-515-2454
Mailing Address - Fax:619-692-0478
Practice Address - Street 1:4040 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2684
Practice Address - Country:US
Practice Address - Phone:619-515-2454
Practice Address - Fax:619-692-0478
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator