Provider Demographics
NPI:1598848830
Name:LECROY, KENNETH DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DOUGLAS
Last Name:LECROY
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 1:6515 COLLEYVILLE BLVD.
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-424-3774
Mailing Address - Fax:817-424-3398
Practice Address - Street 1:6515 COLLEYVILLE BLVD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6231
Practice Address - Country:US
Practice Address - Phone:817-424-3774
Practice Address - Fax:817-424-3398
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2736207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG52259Medicare UPIN
TX00454MMedicare ID - Type Unspecified