Provider Demographics
NPI:1831156447
Name:CLEARY, KEVIN G (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:CLEARY
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 1:4893 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4776
Mailing Address - Country:US
Mailing Address - Phone:716-608-7040
Mailing Address - Fax:
Practice Address - Street 1:4893 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4776
Practice Address - Country:US
Practice Address - Phone:716-608-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200751207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01657083Medicaid
NY01657083Medicaid
NYG31051Medicare UPIN