Provider Demographics
NPI:1144266248
Name:CLARKSTON, WENDELL KEVAN (MD)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:KEVAN
Last Name:CLARKSTON
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 1:901 E 104TH ST
Mailing Address - Street 2:MAILSTOP 400
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-599-9499
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:SUITE 240
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-932-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0429011207RG0100X
MOR1732207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202516639Medicaid
MOW197196Medicare UPIN
C51399Medicare UPIN
MO202516639Medicaid
KSJ947196BMedicare ID - Type Unspecified
KSJ947196BMedicare ID - Type Unspecified