Provider Demographics
NPI:1124193388
Name:BIRD, KENNETH DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DEAN
Last Name:BIRD
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 1:1755 W BROWNING AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2310
Mailing Address - Country:US
Mailing Address - Phone:559-244-1467
Mailing Address - Fax:
Practice Address - Street 1:1221 FULTON MALL
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1915
Practice Address - Country:US
Practice Address - Phone:559-445-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC399952083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70293FMedicaid
CACMM70293FMedicaid