Provider Demographics
NPI:1992921126
Name:DINELLA, KENNETH EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:DINELLA
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 686
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-0686
Mailing Address - Country:US
Mailing Address - Phone:229-928-8868
Mailing Address - Fax:229-928-8919
Practice Address - Street 1:1120 ELM AVE
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709
Practice Address - Country:US
Practice Address - Phone:229-928-8868
Practice Address - Fax:229-928-8919
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA367162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00553253AMedicaid
GA36716OtherSTATE LICENSE NUMBER
GABD1520875OtherDEA NUMBER
GA36716OtherSTATE LICENSE NUMBER
GA58-2057993OtherTAX ID NUMBER
GABD1520875OtherDEA NUMBER