Provider Demographics
NPI:1790735728
Name:SECRIST, NEAL B (DO)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:B
Last Name:SECRIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2131 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-1570
Mailing Address - Country:US
Mailing Address - Phone:316-773-1212
Mailing Address - Fax:316-440-6601
Practice Address - Street 1:2131 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-1570
Practice Address - Country:US
Practice Address - Phone:316-773-1212
Practice Address - Fax:316-440-6601
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS0524232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103897OtherBCBS
KS100232540CMedicaid
KS100232540CMedicaid
KSE42412Medicare UPIN