Provider Demographics
NPI:1104815927
Name:BRADY, KEVIN (DPM)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BRADY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-8873
Mailing Address - Country:US
Mailing Address - Phone:910-343-5300
Mailing Address - Fax:910-254-4680
Practice Address - Street 1:1705 GARDNER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405
Practice Address - Country:US
Practice Address - Phone:910-343-5300
Practice Address - Fax:910-254-4680
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO02717213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390434200Medicaid
FL65579VMedicare PIN
FL390434200Medicaid