Provider Demographics
NPI:1417048331
Name:SON, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:SON
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:PO BOX 2421
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-2421
Mailing Address - Country:US
Mailing Address - Phone:904-202-1034
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1348 S 18TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4785
Practice Address - Country:US
Practice Address - Phone:904-227-2003
Practice Address - Fax:904-277-2006
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043782208800000X
FLME111180208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00748833AMedicaid
FLP01265088OtherRAILROAD MEDICARE
FL004787700Medicaid
FL004787700Medicaid
GA00748833AMedicaid
FLFQ692ZMedicare PIN