Provider Demographics
NPI:1043204654
Name:STAGGS, KENNETH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:STAGGS
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 1:1001 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4458
Mailing Address - Country:US
Mailing Address - Phone:601-482-9224
Mailing Address - Fax:601-482-9223
Practice Address - Street 1:1001 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4458
Practice Address - Country:US
Practice Address - Phone:601-482-9224
Practice Address - Fax:601-482-9223
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14732208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116542Medicaid
MSE45302Medicare UPIN