Provider Demographics
NPI:1588656904
Name:BREGG, KENNETH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:BREGG
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1921 WALDEMERE ST STE 310
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-917-5400
Practice Address - Fax:941-917-5420
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62142208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2780250OtherBCBS FL PROVIDER #
FL373532000Medicaid
FLP00449108OtherRAILROAD MEDICARE
FL1192944OtherWELLCARE
FL202233OtherAMERIGROUP PROVIDER #
FL17793OtherBCBS
FL340017280OtherMEDICARE RR
FL4345646OtherAETNA PROVIDER #
FL202233OtherAMERIGROUP PROVIDER #
FL17793TMedicare PIN
FL17793UMedicare PIN