Provider Demographics
NPI:1104805258
Name:NADEAU, KENNETH ROLLAND (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROLLAND
Last Name:NADEAU
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 1:228 W TYLER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4223
Mailing Address - Country:US
Mailing Address - Phone:870-735-1973
Mailing Address - Fax:870-735-5433
Practice Address - Street 1:228 W TYLER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4223
Practice Address - Country:US
Practice Address - Phone:870-735-1973
Practice Address - Fax:870-735-5433
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN6017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D84301Medicare UPIN
53814Medicare ID - Type Unspecified