Provider Demographics
NPI:1174573000
Name:CLEARY, KEVIN W (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:CLEARY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7725 N 43RD AVE
Mailing Address - Street 2:STE 720
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-5772
Mailing Address - Country:US
Mailing Address - Phone:623-207-5465
Mailing Address - Fax:623-207-5405
Practice Address - Street 1:7725 N 43RD AVE STE 720
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-5772
Practice Address - Country:US
Practice Address - Phone:623-207-5465
Practice Address - Fax:623-207-5405
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ241026Medicaid
AZ241026Medicaid