Provider Demographics
NPI:1821104365
Name:OVERMYER, KENT T (MD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:T
Last Name:OVERMYER
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 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 230A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3485
Mailing Address - Country:US
Mailing Address - Phone:228-831-0204
Mailing Address - Fax:228-831-1868
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 230A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-831-0204
Practice Address - Fax:228-831-1868
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040603A207LP2900X
MS14855207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116845Medicaid
MS050000455Medicare PIN
MSG04242Medicare UPIN
MS00116845Medicaid