Provider Demographics
NPI:1205840428
Name:HOMER, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:HOMER
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 1:5601 N DIXIE HWY
Mailing Address - Street 2:SUITE 412
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4148
Mailing Address - Country:US
Mailing Address - Phone:954-491-2140
Mailing Address - Fax:954-491-9640
Practice Address - Street 1:5601 N DIXIE HWY
Practice Address - Street 2:SUITE 412
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-4148
Practice Address - Country:US
Practice Address - Phone:954-491-2140
Practice Address - Fax:954-491-9640
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 47305207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94498Medicare ID - Type Unspecified
FLD63253Medicare UPIN