Healthcare Provider Details

I. General information

NPI: 1053163832
Provider Name (Legal Business Name): JOHN DEGRAFFENREID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 06/09/2024
Certification Date: 06/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 RAINBOW BLVD # MS 4034
KANSAS CITY KS
66160-8500
US

IV. Provider business mailing address

3901 RAINBOW BLVD # MS 4034
KANSAS CITY KS
66160-8500
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-1908
  • Fax: 913-588-8387
Mailing address:
  • Phone: 913-588-1908
  • Fax: 913-588-8387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94-11744
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: