Provider Demographics
NPI:1205189073
Name:GAUGER, KEVIN DOUGLAS
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:GAUGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1960
Mailing Address - Country:US
Mailing Address - Phone:918-508-7330
Mailing Address - Fax:
Practice Address - Street 1:2140 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1960
Practice Address - Country:US
Practice Address - Phone:918-508-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator