Provider Demographics
NPI:1396890034
Name:KENAN KIRKENDALL, D.O., PC
Entity type:Organization
Organization Name:KENAN KIRKENDALL, D.O., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-254-5316
Mailing Address - Street 1:1501 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3043
Mailing Address - Country:US
Mailing Address - Phone:580-254-5316
Mailing Address - Fax:580-256-6508
Practice Address - Street 1:1501 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-3043
Practice Address - Country:US
Practice Address - Phone:580-254-5316
Practice Address - Fax:580-256-6508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100256120AMedicaid
OKG27565Medicare UPIN
OK447824394PMedicare ID - Type Unspecified