Healthcare Provider Details

I. General information

NPI: 1942203575
Provider Name (Legal Business Name): CARSON KENDALL AGEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N PORTLAND AVE STE 540
OKLAHOMA CITY OK
73112-2092
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE STE 280
OKLAHOMA CITY OK
73112-5555
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-4224
  • Fax: 405-702-4734
Mailing address:
  • Phone: 405-604-4224
  • Fax: 405-702-4734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number048474
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: