Basic Information
| Provider Information | |||||||||
| NPI: | 1790785004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUTLER | ||||||||
| FirstName: | KEVEN | ||||||||
| MiddleName: | ODELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843966 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641843966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738843300 | ||||||||
| FaxNumber: | 5738840943 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 N KEENE ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738759400 | ||||||||
| FaxNumber: | 5738741547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | 36604 | IA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 207PP0204X | 2015031842 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200026023 | 05 | MO | MEDICAID |