Provider Demographics
NPI:1588682983
Name:ANDERSON, KEVIN (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:
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:PO BOX 746088
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6088
Mailing Address - Country:US
Mailing Address - Phone:469-755-3730
Mailing Address - Fax:
Practice Address - Street 1:2000 DIAMOND HILL RD STE 18
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-1554
Practice Address - Country:US
Practice Address - Phone:401-470-7116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7826207R00000X
TN2093207R00000X
RIDO01379207R00000X
MA273031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11013370AMedicaid