Provider Demographics
NPI:1669478830
Name:SOBEL, KENNETH JAY (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAY
Last Name:SOBEL
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 1:575 PROFESSIONAL DR
Mailing Address - Street 2:STE 510
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3336
Mailing Address - Country:US
Mailing Address - Phone:770-513-2072
Mailing Address - Fax:770-513-7986
Practice Address - Street 1:575 PROFESSIONAL DR
Practice Address - Street 2:STE 510
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3336
Practice Address - Country:US
Practice Address - Phone:770-513-2072
Practice Address - Fax:770-513-7986
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-09-15
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
GA024099207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA110064877OtherPALMETTO
GA581854158001OtherTRICARE
GA581854158OtherUHC,HUMANA, CIGNA
GA000435949BMedicaid
GAE00581854158OtherAETNA
GA52067326OtherBCBSGA
GAD30852Medicare UPIN
GA52067326OtherBCBSGA