Provider Demographics
NPI:1609832971
Name:TOMBERLIN, KENNETH GUY (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GUY
Last Name:TOMBERLIN
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 1:3817 FORRESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2930
Mailing Address - Country:US
Mailing Address - Phone:336-765-9314
Mailing Address - Fax:336-765-6610
Practice Address - Street 1:3817 FORRESTGATE DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2930
Practice Address - Country:US
Practice Address - Phone:336-765-9314
Practice Address - Fax:336-765-6610
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC229911964207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC83605OtherBLUE CROSS BLUE SHIELD
0901977OtherUNITED HEALTHCARE
NC8983605Medicaid
NC83605OtherBLUE CROSS BLUE SHIELD