Provider Demographics
NPI:1457342701
Name:DOVER, KEVIN GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GLENN
Last Name:DOVER
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:PO BOX 63112
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3112
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1331 NORTH ELM STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6304
Practice Address - Country:US
Practice Address - Phone:336-274-9617
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-013242085R0202X
NC97013242085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1123GOtherBLUE CROSS BLUE SHIELD
VA1457342701Medicaid
NC1600165OtherUNITED HEALTHCARE
NC25040OtherPARTNERS
NC300123093OtherRAILROAD MEDICARE
NC891123GMedicaid
NCA8187OtherMEDCOST
NC2287166Medicare ID - Type Unspecified
NC891123GMedicaid