Provider Demographics
NPI:1538158985
Name:HARGROVE, KEVIN WAYNE (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WAYNE
Last Name:HARGROVE
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 1:101 S SAINTS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3082
Mailing Address - Country:US
Mailing Address - Phone:405-513-8326
Mailing Address - Fax:405-513-7739
Practice Address - Street 1:101 S SAINTS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3082
Practice Address - Country:US
Practice Address - Phone:405-513-8326
Practice Address - Fax:405-513-7739
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16493174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100101900AMedicaid
244419608Medicare ID - Type Unspecified
E98585Medicare UPIN