Provider Demographics
NPI:1124023940
Name:DERRINGTON, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:DERRINGTON
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:PO BOX 1519
Mailing Address - Street 2:
Mailing Address - City:LAURIE
Mailing Address - State:MO
Mailing Address - Zip Code:65038-1519
Mailing Address - Country:US
Mailing Address - Phone:573-374-5800
Mailing Address - Fax:573-374-5697
Practice Address - Street 1:156 MISSOURI BLVD STE B
Practice Address - Street 2:
Practice Address - City:GRAVOIS MILLS
Practice Address - State:MO
Practice Address - Zip Code:65037-5394
Practice Address - Country:US
Practice Address - Phone:573-374-5263
Practice Address - Fax:573-374-4933
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9A11207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201366010Medicaid
MOR9A11OtherMO LICENSE
MO291966OtherHEALTHLINK
C50286Medicare UPIN
MO000095589Medicare ID - Type Unspecified