Provider Demographics
NPI:1003172495
Name:KLINGLER, KENDELL RYAN (MD)
Entity Type:Individual
Prefix:
First Name:KENDELL
Middle Name:RYAN
Last Name:KLINGLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 E BRIARMEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7704
Mailing Address - Country:US
Mailing Address - Phone:208-390-7555
Mailing Address - Fax:
Practice Address - Street 1:778 E BRIARMEADOW AVE
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7704
Practice Address - Country:US
Practice Address - Phone:208-390-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5068619-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1003172495Medicaid
UTU000094229Medicare UPIN