Provider Demographics
NPI:1174781017
Name:DEANDRADE, KEVIN BLASE (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:BLASE
Last Name:DEANDRADE
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 1:6701 AIRPORT BLVD
Mailing Address - Street 2:SUITE A-107
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6774
Mailing Address - Country:US
Mailing Address - Phone:251-433-4700
Mailing Address - Fax:251-435-8549
Practice Address - Street 1:6701 AIRPORT BLVD
Practice Address - Street 2:SUITE A-107
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6774
Practice Address - Country:US
Practice Address - Phone:251-433-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30054207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1063477644Medicaid
AL1063477644Medicaid