Provider Demographics
NPI:1245216191
Name:GRIDER, KENNY M (DO)
Entity type:Individual
Prefix:DR
First Name:KENNY
Middle Name:M
Last Name:GRIDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1805 W UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-3011
Mailing Address - Country:US
Mailing Address - Phone:580-920-0300
Mailing Address - Fax:580-920-0581
Practice Address - Street 1:1805 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3011
Practice Address - Country:US
Practice Address - Phone:580-920-0300
Practice Address - Fax:580-920-0581
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKDO3262207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100136800AMedicaid
OK200022524OtherRAILROAD MEDICARE
OK100136800AMedicaid
OK$$$$$$$$$Medicare PIN