Provider Demographics
NPI:1437328002
Name:GORDLEY, KYLE PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:PATRICK
Last Name:GORDLEY
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 1:129 VISION PARK BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3024
Mailing Address - Country:US
Mailing Address - Phone:832-813-5839
Mailing Address - Fax:832-813-8512
Practice Address - Street 1:129 VISION PARK BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3024
Practice Address - Country:US
Practice Address - Phone:832-813-5839
Practice Address - Fax:832-813-8512
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM72222086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BD300OtherBC/BS
TX336662701Medicaid
TX8BD300OtherBC/BS