Provider Demographics
NPI:1336292382
Name:KENNETH B. HUDSPETH M.D.
Entity Type:Organization
Organization Name:KENNETH B. HUDSPETH M.D.
Other - Org Name:WIMBERLEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSPETH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-847-6789
Mailing Address - Street 1:12941 RANCH ROAD 12
Mailing Address - Street 2:P.O. BOX 2070
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-5218
Mailing Address - Country:US
Mailing Address - Phone:512-847-6789
Mailing Address - Fax:512-847-7968
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-20
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9503261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00072JMedicare PIN
TXB23626Medicare UPIN