Provider Demographics
NPI:1114925237
Name:VAGUE, KENDALL CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:CHARLES
Last Name:VAGUE
Suffix:
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 1:2950 HIGHWAY 78 E
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-8903
Mailing Address - Country:US
Mailing Address - Phone:205-221-5374
Mailing Address - Fax:205-384-1453
Practice Address - Street 1:2950 HIGHWAY 78 E
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8903
Practice Address - Country:US
Practice Address - Phone:205-221-5374
Practice Address - Fax:205-384-1453
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9565174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL12839OtherBLUE CROSS & BLUE SHIELD
AL0000012839Medicaid
AL12839Medicare ID - Type Unspecified
AL12839OtherBLUE CROSS & BLUE SHIELD