Provider Demographics
NPI:1376801555
Name:PHILLIPS, KENNETH GALE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GALE
Last Name:PHILLIPS
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 1:3415 BRIDGEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5914
Mailing Address - Country:US
Mailing Address - Phone:863-647-2488
Mailing Address - Fax:863-701-7176
Practice Address - Street 1:3415 BRIDGEFIELD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-5914
Practice Address - Country:US
Practice Address - Phone:863-647-2488
Practice Address - Fax:863-701-7176
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME681262083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine