Provider Demographics
NPI:1215913025
Name:TODD, KENNETH LEONARD III (MD, FACPH, RPVI)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEONARD
Last Name:TODD
Suffix:III
Gender:M
Credentials:MD, FACPH, RPVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-3040
Mailing Address - Country:US
Mailing Address - Phone:334-678-9494
Mailing Address - Fax:334-678-8878
Practice Address - Street 1:3280 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-3040
Practice Address - Country:US
Practice Address - Phone:334-678-9494
Practice Address - Fax:334-678-8878
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15348174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL04-01952OtherUNITED HEALTHCARE ID#
AL51077969OtherBLUECROSS BLUESHIELD ID#
AL51077969OtherBLUECROSS BLUESHIELD ID#
AL631193582OtherEIN FOR COMMERCIAL INS
AL04-01952OtherUNITED HEALTHCARE ID#