Provider Demographics
NPI:1194040840
Name:MASTERS, KYLE MITCHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MITCHAM
Last Name:MASTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KYLE
Other - Middle Name:M
Other - Last Name:MASTERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:979-777-6290
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-2491
Practice Address - Fax:210-916-2077
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEDR.0052924207R00000X
NE26526207R00000X
CODR.0052924208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59926066Medicaid
TX59926066Medicaid