Provider Demographics
NPI:1366462061
Name:GERSON, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:GERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:171 N EAGLE CREEK DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1801
Mailing Address - Country:US
Mailing Address - Phone:859-277-9112
Mailing Address - Fax:859-227-7105
Practice Address - Street 1:171 N EAGLE CREEK DR
Practice Address - Street 2:SUITE 106
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1801
Practice Address - Country:US
Practice Address - Phone:859-277-9112
Practice Address - Fax:859-227-7105
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY140562080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000045611OtherBLUE CROSS BLUE SHIELD
KY64140569Medicaid
C65756Medicare UPIN
KY64140569Medicaid
KS5065Medicare ID - Type UnspecifiedMEDICARE