Provider Demographics
NPI:1417935222
Name:WASHINGTON, KENNETH RAYE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAYE
Last Name:WASHINGTON
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 1:201 6TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-2243
Mailing Address - Country:US
Mailing Address - Phone:727-867-1517
Mailing Address - Fax:
Practice Address - Street 1:601 5TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:727-767-4341
Practice Address - Fax:727-767-8516
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37564207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL035976900Medicaid
D63171Medicare UPIN
FL035976900Medicaid