Provider Demographics
NPI:1033315437
Name:REED, KENNETH CALRISIAN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:CALRISIAN
Last Name:REED
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 1:9320 S MINGO RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5710
Mailing Address - Country:US
Mailing Address - Phone:918-901-9701
Mailing Address - Fax:918-901-9702
Practice Address - Street 1:9320 S MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5710
Practice Address - Country:US
Practice Address - Phone:918-901-9701
Practice Address - Fax:918-901-9702
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28440207LP2900X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200337180AMedicaid
OK200337180AMedicaid