Provider Demographics
NPI:1659314540
Name:WALDRON, KEVIN GERARD (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GERARD
Last Name:WALDRON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:122 MANGROVE BANKS
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-7340
Mailing Address - Country:US
Mailing Address - Phone:219-381-0846
Mailing Address - Fax:
Practice Address - Street 1:160 E ARTESIA ST STE 220
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2921
Practice Address - Country:US
Practice Address - Phone:909-865-1020
Practice Address - Fax:909-865-1202
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.113732207T00000X
IN01060759A207T00000X
CAC147602207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200800980Medicaid
IN0375788OtherANTHEM
INP00298697OtherPALMETTO RR MEDICARE
IN129164100OtherINDIANA DEPT OF LABOR
INI30942Medicare UPIN
INP00298697OtherPALMETTO RR MEDICARE