Healthcare Provider Details

I. General information

NPI: 1861487274
Provider Name (Legal Business Name): KENNETH BRENT KUMMERFELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 S FLEISHEL AVE STE 4000
TYLER TX
75701-2015
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-606-7525
  • Fax:
Mailing address:
  • Phone: 903-324-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberF4185
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberF4185
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: