Provider Demographics
NPI:1689649899
Name:HOLLIS, KENNETH WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:HOLLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 58869
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-8869
Mailing Address - Country:US
Mailing Address - Phone:281-482-4300
Mailing Address - Fax:281-482-3159
Practice Address - Street 1:11914 ASTORIA BLVD STE 125
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6073
Practice Address - Country:US
Practice Address - Phone:281-482-4300
Practice Address - Fax:281-482-3159
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ4856208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85030FMedicare PIN