Provider Demographics
NPI:1336266097
Name:HOMERTGEN, KYLE D (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:D
Last Name:HOMERTGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:147 SW SHEVLIN HIXON DR STE 204
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1137
Mailing Address - Country:US
Mailing Address - Phone:541-706-9985
Mailing Address - Fax:541-408-9853
Practice Address - Street 1:147 SW SHEVLIN HIXON DR STE 204
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1137
Practice Address - Country:US
Practice Address - Phone:541-706-9985
Practice Address - Fax:541-408-9853
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2075207Q00000X
ORDO151041204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM