Provider Demographics
NPI:1285833129
Name:POWELL, KENNETH PATRICK (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PATRICK
Last Name:POWELL
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 1:3100 SAMFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4239
Mailing Address - Country:US
Mailing Address - Phone:318-226-3306
Mailing Address - Fax:318-226-3319
Practice Address - Street 1:3100 SAMFORD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4239
Practice Address - Country:US
Practice Address - Phone:318-226-3306
Practice Address - Fax:318-226-3319
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-1987207X00000X
TNMD48720207X00000X
TXP7970207XP3100X
MS23488207XP3100X
LA320573207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08129884Medicaid
TX317064YMJCMedicare PIN
MS08129884Medicaid