Provider Demographics
NPI:1053368498
Name:POTHOVEN, KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:POTHOVEN
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:PO BOX 4925
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4925
Mailing Address - Country:US
Mailing Address - Phone:515-643-4374
Mailing Address - Fax:515-643-2784
Practice Address - Street 1:1111 6TH AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2613
Practice Address - Country:US
Practice Address - Phone:515-247-3211
Practice Address - Fax:515-643-8722
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078608207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06127OtherBC/BS OF IOWA
MI104703457Medicaid
MIKP078608OtherBC/BS OF MICHIGAN
MI104631572Medicaid
IAI20309Medicare PIN
MI104703457Medicaid
MIKP078608OtherBC/BS OF MICHIGAN
MIM48310092Medicare ID - Type Unspecified