Provider Demographics
NPI:1669492658
Name:HIGGINBOTHAM, DENNIS G (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:G
Last Name:HIGGINBOTHAM
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 1:1 MT CARMEL WAY
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-7587
Mailing Address - Country:US
Mailing Address - Phone:620-230-0044
Mailing Address - Fax:620-230-0543
Practice Address - Street 1:1 MT CARMEL WAY
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-7587
Practice Address - Country:US
Practice Address - Phone:620-230-0044
Practice Address - Fax:620-230-0543
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD-107964207V00000X
KS04-25345207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS20-877250-01Medicaid
MO207 967 910Medicaid
KSBH 2825923OtherDEA NUMBER
KS26D0921360OtherCLIA ID NUMBER
KSBH 2825923OtherDEA NUMBER
KS20-877250-01Medicaid