Provider Demographics
NPI:1730173279
Name:O'CONNOR, KEVIN PAUL (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PAUL
Last Name:O'CONNOR
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 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19415 DEERFIELD AVE STE 112
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8470
Practice Address - Country:US
Practice Address - Phone:703-724-1195
Practice Address - Fax:703-724-4495
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048160208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA340017904OtherRR MEDICARE
DC340017905OtherRR MEDICARE
VA1730173279Medicaid
VA340017904OtherRR MEDICARE
VA7503261Medicaid
VA340000658Medicare PIN
DC000Z61L26Medicare PIN