Provider Demographics
NPI:1508804725
Name:ENNIS, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:ENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:75 LINDALL STREET
Mailing Address - Street 2:CENTER FOR HEALTHY AGING
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923
Mailing Address - Country:US
Mailing Address - Phone:978-774-4400
Mailing Address - Fax:
Practice Address - Street 1:75 LINDALL STREET
Practice Address - Street 2:CENTER FOR HEALTHY AGING
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923
Practice Address - Country:US
Practice Address - Phone:978-774-4400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA225012207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine