Provider Demographics
NPI:1649991548
Name:CORDOVA, KEVIN MICHAEL
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:CORDOVA
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 1:2849 46TH ST APT 2L
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1235
Mailing Address - Country:US
Mailing Address - Phone:516-672-7906
Mailing Address - Fax:
Practice Address - Street 1:1090 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1737
Practice Address - Country:US
Practice Address - Phone:212-523-5731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker