Provider Demographics
NPI:1457373466
Name:TOLLER, KEVIN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:KEITH
Last Name:TOLLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 NEO LOOP
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344
Mailing Address - Country:US
Mailing Address - Phone:918-787-2020
Mailing Address - Fax:918-787-6002
Practice Address - Street 1:1120 NEO LOOP
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:918-787-2020
Practice Address - Fax:918-787-6002
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21196207W00000X
ARE2275207W00000X
MO107786207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3910810001OtherMEDICARE DMERC PTAN
OK731567327001OtherBCBS
OK180037253OtherRAILROAD MEDICARE
OK243510200Medicare PIN
OK100138230AMedicaid
OKG95952Medicare UPIN
G95952Medicare UPIN