Provider Demographics
NPI:1437647344
Name:MERRELL, KALE JO (DPM)
Entity Type:Individual
Prefix:DR
First Name:KALE
Middle Name:JO
Last Name:MERRELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 NORTH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-1574
Mailing Address - Country:US
Mailing Address - Phone:605-722-3668
Mailing Address - Fax:605-722-3669
Practice Address - Street 1:1410 NORTH AVE STE 1
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1574
Practice Address - Country:US
Practice Address - Phone:605-722-3668
Practice Address - Fax:605-722-3669
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD253213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1255401196OtherCOMPL.ETE FAMILY FOOT CARE
TX429384701Medicaid
TX018805401Medicaid