Provider Demographics
NPI:1699730762
Name:GANONG, KEVIN D (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:GANONG
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:PO BOX 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8000
Mailing Address - Fax:870-934-3639
Practice Address - Street 1:4802 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8413
Practice Address - Country:US
Practice Address - Phone:870-936-8000
Practice Address - Fax:870-934-3639
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1711207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARG68783Medicare UPIN
AR5K742Medicare ID - Type Unspecified
ARBG5861186Medicaid