Provider Demographics
NPI:1184660698
Name:HEILES, KENNETH A (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:HEILES
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 1:118 SEVEN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-0235
Mailing Address - Country:US
Mailing Address - Phone:352-666-6950
Mailing Address - Fax:352-666-6438
Practice Address - Street 1:203 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667-5101
Practice Address - Country:US
Practice Address - Phone:793-229-5764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3681207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112297003Medicaid
ARB89999Medicare UPIN
AR112297003Medicaid