Provider Demographics
NPI:1053450957
Name:KUYKENDALL, TRACY D (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:KUYKENDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:D
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1218 E 9TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5796
Mailing Address - Country:US
Mailing Address - Phone:405-301-8010
Mailing Address - Fax:888-720-0860
Practice Address - Street 1:1218 E 9TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5952
Practice Address - Country:US
Practice Address - Phone:405-301-8010
Practice Address - Fax:918-994-4403
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23494207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK242722202Medicare PIN