Healthcare Provider Details

I. General information

NPI: 1679539803
Provider Name (Legal Business Name): KEVIN F STAVELEY-OCARROLL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-8063
US

IV. Provider business mailing address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-8063
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-8080
  • Fax: 860-679-1340
Mailing address:
  • Phone: 860-679-8080
  • Fax: 860-679-1340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number076526
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD071461L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2015030565
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number35558
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number2015030565
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: