Provider Demographics
NPI:1265488803
Name:PENIRD, KEVIN DWAIN (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DWAIN
Last Name:PENIRD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6532 ANTHONY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-1403
Mailing Address - Country:US
Mailing Address - Phone:585-924-2100
Mailing Address - Fax:585-924-5920
Practice Address - Street 1:6532 ANTHONY DR STE A
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1422
Practice Address - Country:US
Practice Address - Phone:585-924-2100
Practice Address - Fax:585-398-1217
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211178208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000916471001OtherHEALTH NOW SYRACUSE NY
P010211178OtherBLUE CHOICE ROCHESTER NY
7740257OtherAETNA
110217619OtherRR MEDICARE
1137OtherBC/BS ROCHESTER NY
NY01857212Medicaid
101780BJOtherPREFERRED CARE ROCH NY
7740257OtherAETNA
110217619OtherRR MEDICARE