Provider Demographics
NPI:1265443741
Name:DAVENPORT, KENNETH ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLAN
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-1321
Mailing Address - Fax:906-228-9371
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-1321
Practice Address - Fax:906-228-9371
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301050335207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E26013OtherBLUE CROSS BLUE SHIELD MI
MI1752485Medicaid
MI1752485Medicaid
MI0E26013OtherBLUE CROSS BLUE SHIELD MI