Provider Demographics
NPI:1760481139
Name:TEGELER, KENT (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:
Last Name:TEGELER
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 1:1496 HEMLOCK CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3723
Mailing Address - Country:US
Mailing Address - Phone:816-781-7820
Mailing Address - Fax:816-781-2371
Practice Address - Street 1:2529 GLENN HENDREN DR
Practice Address - Street 2:STE 200
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9607
Practice Address - Country:US
Practice Address - Phone:816-781-7820
Practice Address - Fax:816-781-2371
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC51227Medicare UPIN