Provider Demographics
NPI:1285632075
Name:HUDSPETH, KENNETH B (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:HUDSPETH
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:PO BOX 2070
Mailing Address - Street 2:
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-6970
Mailing Address - Country:US
Mailing Address - Phone:512-847-2126
Mailing Address - Fax:
Practice Address - Street 1:12941 RANCH ROAD 12
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-5218
Practice Address - Country:US
Practice Address - Phone:512-847-6789
Practice Address - Fax:512-847-7968
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2008-01-09
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
TXD9503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00072JMedicare PIN
TXB23626Medicare UPIN