Provider Demographics
NPI:1508929258
Name:KUYKENDALL, SAMUEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:KUYKENDALL
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 1:1203 TROTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4886
Mailing Address - Country:US
Mailing Address - Phone:931-388-1181
Mailing Address - Fax:931-381-5302
Practice Address - Street 1:1203 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4886
Practice Address - Country:US
Practice Address - Phone:931-388-1181
Practice Address - Fax:931-381-5302
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN621078139174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2007555OtherBLUE CROSS BLUE SHIELD
TN3177644Medicaid
TNB59400Medicare UPIN
TN3177644Medicare PIN