Provider Demographics
NPI:1013018159
Name:CROSBY, KENNETH LEE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:CROSBY
Suffix:JR
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 1:5220 GREENS DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-4612
Mailing Address - Country:US
Mailing Address - Phone:919-256-3576
Mailing Address - Fax:
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1109
Practice Address - Country:US
Practice Address - Phone:434-200-5047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2001010322084P0800X, 2085R0202X
VA01012713242085R0202X
SC852142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1013018159Medicaid
NCNC6987HOtherNC MEDICARE PTAN
NC89129TCMedicaid