Provider Demographics
NPI:1336110907
Name:MCDONALD, KENNETH E III (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:MCDONALD
Suffix:III
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 1:508 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:LA
Mailing Address - Zip Code:71232-3002
Mailing Address - Country:US
Mailing Address - Phone:318-878-3737
Mailing Address - Fax:318-878-8638
Practice Address - Street 1:508 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:LA
Practice Address - Zip Code:71232-3002
Practice Address - Country:US
Practice Address - Phone:318-878-3737
Practice Address - Fax:318-878-8638
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013381207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA013381OtherLICENSE
LA1188476Medicaid
53896Medicare ID - Type Unspecified
C67584Medicare UPIN