Provider Demographics
NPI:1720262686
Name:O'CONNELL, KEVIN A (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
Last Name:O'CONNELL
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 1:400 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-1025
Mailing Address - Country:US
Mailing Address - Phone:585-786-1555
Mailing Address - Fax:585-786-7983
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1025
Practice Address - Country:US
Practice Address - Phone:585-786-1555
Practice Address - Fax:585-786-7983
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041918207YX0602X
NY191328207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY191328OtherNYS MEDICAL LICENSE
GA000711301AMedicaid
GA040013774OtherRAIL ROAD MEDICARE
GA584912OtherBLUE CROSS BLUE SHIELD
GA308584OtherWELLCARE
GA308584OtherWELLCARE
GA000711301AMedicaid