Provider Demographics
NPI:1669640348
Name:GAGE, KENNETH LESLIE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LESLIE
Last Name:GAGE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:MAILSTOP WCB-RAD MD/OPI
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-1573
Mailing Address - Fax:813-745-6070
Practice Address - Street 1:26972 EVERGREEN CHASE DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6683
Practice Address - Country:US
Practice Address - Phone:813-745-7365
Practice Address - Fax:813-449-8618
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1195902085R0202X, 207U00000X, 2085N0904X
MDD0074165207U00000X, 2085R0202X
MDD741652085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine