Provider Demographics
NPI:1033102702
Name:KONZEN, KEVIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:KONZEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4921 PARKVIEW PL
Mailing Address - Street 2:STE 13A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1032
Mailing Address - Country:US
Mailing Address - Phone:314-333-4100
Mailing Address - Fax:314-333-4115
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:STE 13A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-333-4100
Practice Address - Fax:314-333-4115
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO104494207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208096214Medicaid
K11156Medicare ID - Type Unspecified
IL036075200Medicaid