Provider Demographics
NPI:1376746743
Name:OSTROM, KYLE FRITZ (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:FRITZ
Last Name:OSTROM
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 1:901 PATIENTS FIRST DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-239-7500
Mailing Address - Fax:636-239-2836
Practice Address - Street 1:901 PATIENTS FIRST DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4700
Practice Address - Country:US
Practice Address - Phone:636-239-7500
Practice Address - Fax:636-239-2836
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008009982207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01135357OtherRAILROAD MEDICARE
MO1376746743Medicaid
MOP01135357OtherRAILROAD MEDICARE
129430002Medicare PIN