Healthcare Provider Details

I. General information

NPI: 1457331324
Provider Name (Legal Business Name): KENT DOUGLAS MCINTIRE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 W 32ND ST
JOPLIN MO
64804
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-6767
  • Fax: 417-347-6769
Mailing address:
  • Phone: 417-347-6767
  • Fax: 417-347-3170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number3367
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number0526010
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberR5N23
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: