Provider Demographics
NPI:1740361849
Name:REPPERT, EARL JAY (MD)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:JAY
Last Name:REPPERT
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 1:1133 COLLEGE AVE
Mailing Address - Street 2:SUITE E-110
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2770
Mailing Address - Country:US
Mailing Address - Phone:785-537-2651
Mailing Address - Fax:785-537-4276
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:SUITE E-110
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-537-2651
Practice Address - Fax:785-537-4276
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-20073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100161400CMedicaid
KS068002182OtherMEDICARE PTAN
KS100161400CMedicaid