Provider Demographics
NPI:1083695159
Name:SHANK, KENNETH DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DOUGLAS
Last Name:SHANK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-3403
Mailing Address - Country:US
Mailing Address - Phone:704-983-3508
Mailing Address - Fax:704-983-3509
Practice Address - Street 1:815 N 3RD ST
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3403
Practice Address - Country:US
Practice Address - Phone:704-983-3508
Practice Address - Fax:704-983-3509
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89132T2Medicaid
H38709Medicare UPIN
NC89132T2Medicaid