Provider Demographics
NPI:1659312585
Name:STUBBS, KENNETH W (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:STUBBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:46 SEARGENT PRENTISS DR.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120
Mailing Address - Country:US
Mailing Address - Phone:601-446-2084
Mailing Address - Fax:601-442-3024
Practice Address - Street 1:46 SERGEANT PRENTISS DR.
Practice Address - Street 2:SUITE 300
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120
Practice Address - Country:US
Practice Address - Phone:601-446-2084
Practice Address - Fax:601-442-3024
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA15220207R00000X
MS09681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012515Medicaid
MS00012515Medicaid
MSB65034Medicare UPIN