Healthcare Provider Details

I. General information

NPI: 1740329671
Provider Name (Legal Business Name): MATTHEW A KIENSTRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 S FREMONT AVE SUITE 120
SPRINGFIELD MO
65804-2201
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-887-3223
  • Fax: 417-820-3955
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2006003278
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number2006003278
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: