Provider Demographics
NPI:1376640045
Name:GOWDY, KENNETH LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:GOWDY
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 1:16666 BIDWELL LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1454
Mailing Address - Country:US
Mailing Address - Phone:316-641-1497
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER ARMY MEDICAL CENTER
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24690207L00000X
ORMD204530207L00000X
MO2004023916207L00000X
HIMD-18844207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025589200Medicaid