Provider Demographics
NPI:1508864125
Name:WEST, KENNETH W (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:WEST
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 1:1002 TEXAS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-5107
Mailing Address - Country:US
Mailing Address - Phone:903-792-4808
Mailing Address - Fax:903-792-2681
Practice Address - Street 1:1002 TEXAS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5107
Practice Address - Country:US
Practice Address - Phone:903-792-4808
Practice Address - Fax:903-792-2681
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2745174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
H44292Medicare UPIN
TX8C8534Medicare ID - Type Unspecified