Healthcare Provider Details

I. General information

NPI: 1013979061
Provider Name (Legal Business Name): KEN KUYKENDALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S 38TH ST
MUSKOGEE OK
74401-4937
US

IV. Provider business mailing address

333 S 38TH ST
MUSKOGEE OK
74401-4937
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-8631
  • Fax: 918-682-2280
Mailing address:
  • Phone: 918-682-8631
  • Fax: 918-682-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11397
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: