Provider Demographics
NPI:1285799841
Name:KINDELL, GARY R (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:KINDELL
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 1:356110 E 930 RD
Mailing Address - Street 2:
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-5184
Mailing Address - Country:US
Mailing Address - Phone:918-968-9531
Mailing Address - Fax:907-631-5099
Practice Address - Street 1:356110 E 930 RD
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-5184
Practice Address - Country:US
Practice Address - Phone:918-968-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6365202K00000X
OK15655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK161799OtherMEDICARE NO.
AKMD0340OtherMEDICAID NO.
AKMD0340OtherMEDICAID NO.
AKMD0340OtherMEDICAID NO.
OK244508203Medicare ID - Type UnspecifiedPROVIDER MEDICARE NUMBER