Provider Demographics
NPI:1205829371
Name:MACDONALD, KENNETH G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:MACDONALD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1850 W ARLINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5704
Mailing Address - Country:US
Mailing Address - Phone:252-413-6735
Mailing Address - Fax:252-752-2019
Practice Address - Street 1:1850 W ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5704
Practice Address - Country:US
Practice Address - Phone:252-413-6735
Practice Address - Fax:252-752-2019
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27238208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC53661OtherBCBS NC
NC20033818OtherRAILROAD MEDICARE
NC8953661Medicaid
NC208410Medicare ID - Type Unspecified
NC20033818OtherRAILROAD MEDICARE