Provider Demographics
NPI:1902814361
Name:DAUGHTREY, KENNETH RAY JR (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAY
Last Name:DAUGHTREY
Suffix:JR
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:SEMINARY
Mailing Address - State:MS
Mailing Address - Zip Code:39479-0055
Mailing Address - Country:US
Mailing Address - Phone:601-506-7468
Mailing Address - Fax:601-429-9403
Practice Address - Street 1:701 S HOLLY AVE
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-3894
Practice Address - Country:US
Practice Address - Phone:601-765-6711
Practice Address - Fax:601-698-0186
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS115162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04475520Medicaid
MS04475520Medicaid
MS080261602Medicare ID - Type Unspecified