Healthcare Provider Details

I. General information

NPI: 1194948778
Provider Name (Legal Business Name): SAMUEL KUYKENDALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 WASHINGTON ST STE 5300
KANSAS CITY MO
64111-5931
US

IV. Provider business mailing address

4321 WASHINGTON ST STE 5300
KANSAS CITY MO
64111-5931
US

V. Phone/Fax

Practice location:
  • Phone: 816-531-1234
  • Fax: 816-531-0737
Mailing address:
  • Phone: 816-531-1234
  • Fax: 816-531-0737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number04-35782
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2012017449
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: