Provider Demographics
NPI:1003998071
Name:HART, KENNETH R (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:HART
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2935 THOUSAND OAKS
Mailing Address - Street 2:SUITE 294
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3312
Mailing Address - Country:US
Mailing Address - Phone:210-494-1100
Mailing Address - Fax:210-494-1117
Practice Address - Street 1:5101 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4801
Practice Address - Country:US
Practice Address - Phone:210-592-5349
Practice Address - Fax:210-592-5462
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2015-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXF8504174400000X, 2083A0100X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No174400000XOther Service ProvidersSpecialist
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081285101Medicaid
TX081285102Medicaid
TX132637302Medicaid
TXG10066Medicare UPIN
TX081285102Medicaid
TX081285101Medicaid