Basic Information
| Provider Information | |||||||||
| NPI: | 1679573729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMAHON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 546 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064506600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032352511 | ||||||||
| FaxNumber: | 2036390809 | ||||||||
| Practice Location | |||||||||
| Address1: | 546 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064506600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032352511 | ||||||||
| FaxNumber: | 2036390809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 031598 | CT | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 001315987 | 05 | CT | MEDICAID | 180014360 | 01 | CT | RAILROAD MEDICARE | OTHER | 010031598CT02 | 01 | CT | ANTHEM | OTHER | NHS428 | 01 | CT | OXFORD | OTHER | 0R0104 | 01 | CT | HEALTH NET | OTHER | 031598 | 01 | CT | CONNECTICARE | OTHER |