Provider Demographics
NPI:1710076948
Name:GRIFFIN, KYLE W (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:W
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3800 S NATIONAL AVE STE 700
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5279
Practice Address - Country:US
Practice Address - Phone:417-269-8817
Practice Address - Fax:417-269-8744
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO176566OtherBCMO
MO200659803Medicaid
200050038Medicare PIN
H80284Medicare UPIN
MO176566OtherBCMO