Provider Demographics
NPI:1699745562
Name:CIVELLO, KENNETH CHARLES JR (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CHARLES
Last Name:CIVELLO
Suffix:JR
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:222-526-0001
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 1000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-767-3900
Practice Address - Fax:225-766-2226
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA201354207RC0000X, 207RC0001X
OH35084798207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1006122OtherQUAL
LA1108910Medicaid
OH114845OtherKAISER
OHE84798OtherSUMMA
OH000000364128OtherANTHEM
P00225594OtherRAILROAD MEDICARE
OH2515157Medicaid
OH114845OtherKAISER
OHE84798OtherSUMMA