Healthcare Provider Details

I. General information

NPI: 1841286333
Provider Name (Legal Business Name): KEVIN M PENWELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11808 S MAY AVE
OKLAHOMA CITY OK
73170-2560
US

IV. Provider business mailing address

5701 SE 74TH ST SUITE E
OKLAHOMA CITY OK
73135-1106
US

V. Phone/Fax

Practice location:
  • Phone: 405-735-2370
  • Fax: 405-735-2369
Mailing address:
  • Phone: 405-600-6869
  • Fax: 405-600-6978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number3873
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: