Healthcare Provider Details

I. General information

NPI: 1770901670
Provider Name (Legal Business Name): KEVIN O'MALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2014
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 RESERVOIR RD NW DEPT. OF ORTHOPAEDIC SURGERY
WASHINGTON DC
20007-2113
US

IV. Provider business mailing address

4654 CHARLESTON TER NW
WASHINGTON DC
20007-1900
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-8766
  • Fax:
Mailing address:
  • Phone: 253-318-2281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD048567
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: