Provider Demographics
NPI:1528034717
Name:KILLIAN, KENT L (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:L
Last Name:KILLIAN
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 1:16555 MANCHESTER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1220
Mailing Address - Country:US
Mailing Address - Phone:636-458-5858
Mailing Address - Fax:
Practice Address - Street 1:16555 MANCHESTER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1220
Practice Address - Country:US
Practice Address - Phone:636-458-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6P03208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG40304Medicare UPIN