Provider Demographics
NPI:1982601084
Name:ROELOFS, KEVIN JON (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JON
Last Name:ROELOFS
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 1:100 GRIFFIN RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 GRIFFIN RD
Practice Address - Street 2:UNIT A
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7158
Practice Address - Country:US
Practice Address - Phone:603-436-7897
Practice Address - Fax:603-436-7855
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH124042080P0201X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH01Y007809NH01OtherANTHEM NH ID #
NH30204663Medicaid
NHRE7867Medicare ID - Type Unspecified
NH30204663Medicaid