Provider Demographics
NPI:1730186222
Name:REAGAN, KEVIN J (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:REAGAN
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 1:35 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1939
Mailing Address - Country:US
Mailing Address - Phone:860-963-2133
Mailing Address - Fax:860-963-8955
Practice Address - Street 1:35 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1939
Practice Address - Country:US
Practice Address - Phone:860-963-2133
Practice Address - Fax:860-963-8955
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036021204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001360213Medicaid
CT001360213Medicaid
G47153Medicare UPIN