Provider Demographics
NPI:1629159017
Name:PHILLIPS, KENNETH (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 NOKOMIS CIR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-5137
Mailing Address - Country:US
Mailing Address - Phone:972-218-6506
Mailing Address - Fax:972-218-7611
Practice Address - Street 1:931 NOKOMIS CIR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-5137
Practice Address - Country:US
Practice Address - Phone:972-218-6506
Practice Address - Fax:972-218-7611
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1512207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA67503Medicare UPIN