Provider Demographics
NPI:1578710141
Name:CHAVIS, KENYON MALA (MD)
Entity Type:Individual
Prefix:DR
First Name:KENYON
Middle Name:MALA
Last Name:CHAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:901 DENIM DR
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28339-2307
Mailing Address - Country:US
Mailing Address - Phone:910-897-5521
Mailing Address - Fax:910-897-2003
Practice Address - Street 1:901 DENIM DR
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:NC
Practice Address - Zip Code:28339-2307
Practice Address - Country:US
Practice Address - Phone:910-897-5521
Practice Address - Fax:910-897-2003
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01349207R00000X
NC200801349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910124Medicaid
NC2022721Medicare PIN