Provider Demographics
NPI:1063413656
Name:GROOM, KYLE (DO)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:GROOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 N CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:TX
Mailing Address - Zip Code:75559-1406
Mailing Address - Country:US
Mailing Address - Phone:903-667-2273
Mailing Address - Fax:903-667-7597
Practice Address - Street 1:216 N CENTRE ST
Practice Address - Street 2:
Practice Address - City:DE KALB
Practice Address - State:TX
Practice Address - Zip Code:75559-1406
Practice Address - Country:US
Practice Address - Phone:903-667-2273
Practice Address - Fax:903-667-7597
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5749207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H55116Medicare UPIN
TX8F6409Medicare PIN