Provider Demographics
NPI:1477659464
Name:HOLDER, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:HOLDER
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 1:264 SOUTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5829
Mailing Address - Country:US
Mailing Address - Phone:870-336-2976
Mailing Address - Fax:870-931-0665
Practice Address - Street 1:264 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5829
Practice Address - Country:US
Practice Address - Phone:870-336-2976
Practice Address - Fax:870-931-0665
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7966208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64320625Medicaid
KY32062OtherLICENSE
ARE-7966OtherLICENSE
000000044326OtherBCBS PROVIDER NUMBER
KY64320625Medicaid
000000044326OtherBCBS PROVIDER NUMBER
KY32062OtherLICENSE
525608Medicare PIN
KY00280137Medicare PIN
KY080149104Medicare PIN