Provider Demographics
NPI:1861055816
Name:KWAMIN, DELALI KEVIN (MD)
Entity type:Individual
Prefix:
First Name:DELALI
Middle Name:KEVIN
Last Name:KWAMIN
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 1:9953 E HILL DR
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2431
Mailing Address - Country:US
Mailing Address - Phone:571-344-0013
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:800-836-7536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251181390200000X
PAMT222608390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program