Provider Demographics
NPI:1245435213
Name:GAZENKO, KATE ROXALYN (MD)
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:ROXALYN
Last Name:GAZENKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3417
Mailing Address - Country:US
Mailing Address - Phone:479-705-2310
Mailing Address - Fax:479-705-2300
Practice Address - Street 1:1 MEDICINE DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-4431
Practice Address - Country:US
Practice Address - Phone:479-754-6510
Practice Address - Fax:479-754-5644
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.099672208600000X
390200000X
ARE9331208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210971001Medicaid
OHH240820Medicare PIN