Provider Demographics
NPI:1457331324
Name:MCINTIRE, KENT DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:DOUGLAS
Last Name:MCINTIRE
Suffix:
Gender:M
Credentials:DO
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 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-6767
Mailing Address - Fax:417-347-3170
Practice Address - Street 1:1331 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-347-6767
Practice Address - Fax:417-347-6769
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3367207YX0905X
KS0526010207YX0905X
MOR5N23207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO247988108Medicaid
MO9102OtherBLUE CROSS
E65941Medicare UPIN