Provider Demographics
NPI:1407917792
Name:SOUTHERN, KENDALL WAYNE (DO, DPH)
Entity Type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:WAYNE
Last Name:SOUTHERN
Suffix:
Gender:M
Credentials:DO, DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-0069
Mailing Address - Country:US
Mailing Address - Phone:918-261-3612
Mailing Address - Fax:918-256-2952
Practice Address - Street 1:24800 S 4420 RD
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301
Practice Address - Country:US
Practice Address - Phone:918-256-7841
Practice Address - Fax:918-256-2952
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9440183500000X
OK2333207Q00000X, 2084P0800X
TXH94262084P0800X
ALDO-6412084P0800X
GA484642084P0800X
MI51010098362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No183500000XPharmacy Service ProvidersPharmacist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100124360AMedicaid
OKE09679Medicare UPIN