Provider Demographics
NPI:1649200460
Name:YANG, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:YANG
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 1:6445 HARRIS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4138
Mailing Address - Country:US
Mailing Address - Phone:817-870-7300
Mailing Address - Fax:
Practice Address - Street 1:900 W MAGNOLIA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8517
Practice Address - Country:US
Practice Address - Phone:817-870-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6725207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165495601Medicaid
TX8L0693Medicare PIN
TXI05369Medicare UPIN