Provider Demographics
NPI:1114905221
Name:WATSON, KENNETH R (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:WATSON
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 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:214-932-8029
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:10330 HICKMAN MILLS DR
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64137-1618
Practice Address - Country:US
Practice Address - Phone:816-412-7004
Practice Address - Fax:816-763-7536
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8692207ZP0102X
CA20A9489207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS241950005Medicaid
KS100229790AMedicaid
MO6621444Medicare PIN
KS100229790AMedicaid
KS241950005Medicaid