Provider Demographics
NPI:1487623260
Name:KIBURZ, DOUGLAS W (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:KIBURZ
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:660-826-5890
Mailing Address - Fax:
Practice Address - Street 1:2301 S INGRAM AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-8121
Practice Address - Country:US
Practice Address - Phone:660-826-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5F84207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509999207Medicaid
MO509999207Medicaid
MOE07817Medicare UPIN
MO4232420001Medicare NSC