Provider Demographics
NPI:1063621332
Name:LLEWELLYN, KEVIN T (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:LLEWELLYN
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 1:1854 SAWNEE BEAN RD
Mailing Address - Street 2:
Mailing Address - City:THETFORD CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05075-8868
Mailing Address - Country:US
Mailing Address - Phone:336-462-9317
Mailing Address - Fax:
Practice Address - Street 1:MOUNT SINAI ELMHURST HOSPITAL DEPT OF RADIOLOGY
Practice Address - Street 2:79-01 BROADWAY ROOM, A1-19
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-334-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-76372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913923Medicaid
NC2076306DMedicare PIN
NC2076306AMedicare PIN
NC5913923Medicaid
NC2076306CMedicare PIN