Provider Demographics
NPI:1215943295
Name:HANKS, KEVIN MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MATTHEW
Last Name:HANKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1582 ELK CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-542-5414
Mailing Address - Fax:208-552-2708
Practice Address - Street 1:1582 ELK CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-542-5414
Practice Address - Fax:208-552-2708
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-0401207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80756400Medicaid
ID1369849Medicare PIN