Provider Demographics
NPI:1912946278
Name:LAND, KEVIN JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JEFFREY
Last Name:LAND
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 1:28173 RUFFIAN DR
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:TX
Mailing Address - Zip Code:78015-4807
Mailing Address - Country:US
Mailing Address - Phone:817-412-5610
Mailing Address - Fax:817-412-5991
Practice Address - Street 1:210 W CATALDO AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2217
Practice Address - Country:US
Practice Address - Phone:877-258-4825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1263174400000X
TXK2163207ZB0001X
AZ53404207ZB0001X
CO46104207ZB0001X
WAMD.MD.60250244207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10278790OtherPDMP
TX015085801Medicaid
BL6872419OtherDEA