Provider Demographics
NPI:1689964215
Name:GUMMELT, KYLE LAMAR (DO)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:LAMAR
Last Name:GUMMELT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8215 WESTCHESTER DR STE 320
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-6117
Mailing Address - Country:US
Mailing Address - Phone:972-993-5040
Mailing Address - Fax:972-993-5041
Practice Address - Street 1:8215 WESTCHESTER DR STE 320
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-6117
Practice Address - Country:US
Practice Address - Phone:972-993-5040
Practice Address - Fax:972-993-5041
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-16
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4653207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363659YNQJMedicare PIN