Provider Demographics
NPI:1578524369
Name:MASHBURN, KENNETH E (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:MASHBURN
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 1:1006 HILL ST SW
Mailing Address - Street 2:
Mailing Address - City:HARTSELLE
Mailing Address - State:AL
Mailing Address - Zip Code:35640-2802
Mailing Address - Country:US
Mailing Address - Phone:256-773-9756
Mailing Address - Fax:256-773-9401
Practice Address - Street 1:1006 HILL ST SW
Practice Address - Street 2:
Practice Address - City:HARTSELLE
Practice Address - State:AL
Practice Address - Zip Code:35640-2802
Practice Address - Country:US
Practice Address - Phone:256-773-9756
Practice Address - Fax:256-773-9401
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F83307Medicare UPIN