Provider Demographics
NPI:1770567265
Name:PHELPS, KEVIN ANDREW (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDREW
Last Name:PHELPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-5555
Mailing Address - Fax:419-383-3113
Practice Address - Street 1:3333 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614
Practice Address - Country:US
Practice Address - Phone:419-383-5555
Practice Address - Fax:419-383-3113
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0729715Medicaid
E57703Medicare UPIN
OHPH0634591Medicare ID - Type Unspecified
OH0729715Medicaid