Provider Demographics
NPI:1841308277
Name:KEAGLE, KEVIN DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DAVID
Last Name:KEAGLE
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:PO BOX 15109
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28408-5109
Mailing Address - Country:US
Mailing Address - Phone:910-392-2525
Mailing Address - Fax:910-392-2827
Practice Address - Street 1:1709 S 16TH ST STE A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6491
Practice Address - Country:US
Practice Address - Phone:910-452-8633
Practice Address - Fax:901-452-8569
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023-02548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNNT761AOtherMEDICARE
NC1841308277Medicaid
IL036110387Medicaid
ILP01090243OtherRAILROAD MEDICARE PTAN (INDIVIDUAL)
IL920540023OtherMEDICARE PTAN (INDIVIDUAL)
ILCE8792OtherRAILROAD MEDICARE PTAN (GROUP)