Provider Demographics
NPI:1366457012
Name:GOOLSBY, KENNETH E (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:GOOLSBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 S ENOTA DR NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3473
Mailing Address - Country:US
Mailing Address - Phone:770-534-8832
Mailing Address - Fax:770-531-7479
Practice Address - Street 1:200 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3473
Practice Address - Country:US
Practice Address - Phone:770-534-8832
Practice Address - Fax:770-531-7479
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0251622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00358586CMedicaid
GAD29599Medicare UPIN
GA00358586CMedicaid