Provider Demographics
NPI:1124119458
Name:FENNER, DAVID KENNETH (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:KENNETH
Last Name:FENNER
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 1:1505 W ELK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2848
Mailing Address - Country:US
Mailing Address - Phone:423-543-1261
Mailing Address - Fax:423-543-7500
Practice Address - Street 1:1505 W ELK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2848
Practice Address - Country:US
Practice Address - Phone:423-543-1261
Practice Address - Fax:423-543-7500
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000008020170100000X
TN8020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ002461Medicaid
TNP01302537OtherRR MEDICARE
TNTN0108OtherAMERICHOICE
TN110147422OtherRAILROAD MEDICARE
TN202731OtherBLUECROSS BLUESHIELD
TN202731OtherBLUECARE
TNTN0108OtherAMERICHOICE
TN110147422OtherRAILROAD MEDICARE
TN10311I7611Medicare PIN
TN3175303Medicare PIN