Provider Demographics
NPI:1669859054
Name:GRIFFIN, KENNETH SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SCOTT
Last Name:GRIFFIN
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 1:18415 N 46TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-1571
Mailing Address - Country:US
Mailing Address - Phone:951-813-0039
Mailing Address - Fax:
Practice Address - Street 1:395 W BULLDOG BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3311
Practice Address - Country:US
Practice Address - Phone:801-357-7420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11463472-12052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology