Provider Demographics
NPI:1841286333
Name:PENWELL, KEVIN M (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:PENWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5701 SE 74TH ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-1106
Mailing Address - Country:US
Mailing Address - Phone:405-600-6869
Mailing Address - Fax:405-600-6978
Practice Address - Street 1:11808 S MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-2560
Practice Address - Country:US
Practice Address - Phone:405-735-2370
Practice Address - Fax:405-735-2369
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3873207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100113200DMedicaid
OK100113200DMedicaid
H47555Medicare UPIN
OK246616603Medicare PIN