Healthcare Provider Details

I. General information

NPI: 1134383250
Provider Name (Legal Business Name): KIPLAN TREY MENEFEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 SAINT MICHAEL DR SUITE 301
TEXARKANA TX
75503-2387
US

IV. Provider business mailing address

7401 VOLGA AVE
TEXARKANA TX
75503-9593
US

V. Phone/Fax

Practice location:
  • Phone: 903-614-5258
  • Fax: 903-614-5260
Mailing address:
  • Phone: 903-277-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberN2658
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: