Healthcare Provider Details

I. General information

NPI: 1790785004
Provider Name (Legal Business Name): KEVEN ODELL CUTLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 10/05/2022
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N KEENE ST
COLUMBIA MO
65201-6626
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-875-9400
  • Fax: 573-874-1547
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number36604
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number2015031842
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: