Provider Demographics
NPI:1669108510
Name:BAUER, KYLE WILLIAM
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:WILLIAM
Last Name:BAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 FERNBROOK ST
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-1514
Mailing Address - Country:US
Mailing Address - Phone:937-723-1590
Mailing Address - Fax:
Practice Address - Street 1:7301 POE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2559
Practice Address - Country:US
Practice Address - Phone:937-280-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002714175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist