Provider Demographics
NPI:1578559027
Name:STONE, KENNETH DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DAVID
Last Name:STONE
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 1:121 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5239
Mailing Address - Country:US
Mailing Address - Phone:573-471-0200
Mailing Address - Fax:573-472-3026
Practice Address - Street 1:121 SMITH AVE
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5239
Practice Address - Country:US
Practice Address - Phone:573-471-0200
Practice Address - Fax:573-472-3026
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO37010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203159215Medicaid
MO203159215Medicaid
F05464Medicare UPIN