Healthcare Provider Details

I. General information

NPI: 1578787735
Provider Name (Legal Business Name): KEVIN W O'BRYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S 2ND ST
LOUISVILLE KY
40202-2862
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-3429
  • Fax: 502-583-7546
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number256380
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number256380
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number48776
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number256380
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number01076508A
License Number StateIN
# 6
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number48776
License Number StateKY
# 7
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number01076508A
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number48776
License Number StateKY
# 9
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01076508A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: