Provider Demographics
NPI:1194778910
Name:KILLMAN, MARK RAY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAY
Last Name:KILLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:14607 GRANADA ST
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-3703
Mailing Address - Country:US
Mailing Address - Phone:913-544-1956
Mailing Address - Fax:
Practice Address - Street 1:19550 E 39TH ST S
Practice Address - Street 2:SUITE 415
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2303
Practice Address - Country:US
Practice Address - Phone:816-254-9595
Practice Address - Fax:816-836-3810
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107716225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0008970Medicare ID - Type Unspecified
MOF40986Medicare UPIN