Provider Demographics
NPI:1740329671
Name:KIENSTRA, MATTHEW A (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:KIENSTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-887-3223
Practice Address - Fax:417-820-3955
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006003278207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160592001Medicaid
MO200586204Medicaid
MO204558OtherMO BLUE SHIELD
AR83878OtherARK BLUE SHIELD
AR160592001Medicaid
MO200586204Medicaid