Provider Demographics
NPI:1306872940
Name:KEPHART, WILLIS H (MD)
Entity type:Individual
Prefix:
First Name:WILLIS
Middle Name:H
Last Name:KEPHART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:
Other - Last Name:KEPHART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6100 PAN AMERICAN EAST FWY NE
Mailing Address - Street 2:STE 100
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3427
Mailing Address - Country:US
Mailing Address - Phone:505-727-4500
Mailing Address - Fax:505-727-4505
Practice Address - Street 1:4705 MONTGOMERY BLVD NE
Practice Address - Street 2:STE 301
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1226
Practice Address - Country:US
Practice Address - Phone:505-727-4500
Practice Address - Fax:505-727-4505
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000165660207VG0400X
NM81-243207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100327540BMedicaid
MO595985805Medicaid
MO540568508Medicaid
NM32771Medicaid
MO599225901Medicaid
OK100188410AMedicaid
KS90036022Medicaid
MO205083603Medicaid
MO595956103Medicaid
MO595956202Medicaid
MO010568509Medicaid
MO595956400Medicaid
MO595985805Medicaid
268550Medicare Oscar/Certification
261320Medicare PIN
KS90036022Medicaid
MO595956400Medicaid
P270000Medicare PIN
P00720076Medicare PIN
MO000094920Medicare PIN
KS100327540BMedicaid
MO205083603Medicaid
NM32771Medicaid
MO540568508Medicaid
160049778OtherRR MEDICARE
KS100327540BMedicaid
MO595956202Medicaid