Provider Demographics
NPI:1699747329
Name:HEFNER, KENNY DEWAYNE (MD)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:DEWAYNE
Last Name:HEFNER
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-651-2980
Mailing Address - Fax:336-667-2047
Practice Address - Street 1:1919 W PARK DR
Practice Address - Street 2:
Practice Address - City:N WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3564
Practice Address - Country:US
Practice Address - Phone:336-651-2980
Practice Address - Fax:336-667-2047
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-00276208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891062AMedicaid
NC2239875Medicare ID - Type Unspecified
NC891062AMedicaid
NC2239875AMedicare PIN