Healthcare Provider Details

I. General information

NPI: 1134657109
Provider Name (Legal Business Name): KEVIN MICHAEL MCNULTY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8051 S EMERSON AVE STE 250
INDIANAPOLIS IN
46237-8637
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1008
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-6670
  • Fax: 317-528-6671
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

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 Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number02005673A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02005673A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: