Provider Demographics
NPI:1306886825
Name:ATAGA, KENNETH I (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:I
Last Name:ATAGA
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 1:1325 EASTMORELAND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3507
Mailing Address - Country:US
Mailing Address - Phone:901-516-8785
Mailing Address - Fax:901-516-8358
Practice Address - Street 1:1325 EASTMORELAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:901-516-8785
Practice Address - Fax:901-516-8358
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700849207RH0003X
TN57803207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ037997Medicaid
NC2244743Medicare ID - Type Unspecified
NC8910565Medicaid