Provider Demographics
NPI:1558854414
Name:WALPOLE, KEVIN CLARKE
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CLARKE
Last Name:WALPOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 S BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-1559
Practice Address - Country:US
Practice Address - Phone:856-516-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT018658207Q00000X
NJ25MB11701100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine