Provider Demographics
NPI:1710042940
Name:WILSON, KENNETH CARL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CARL
Last Name:WILSON
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:PO BOX 35070
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40232-5070
Mailing Address - Country:US
Mailing Address - Phone:502-629-5578
Mailing Address - Fax:502-629-5147
Practice Address - Street 1:234 E GRAY ST
Practice Address - Street 2:SUITE 364
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1900
Practice Address - Country:US
Practice Address - Phone:502-629-5578
Practice Address - Fax:502-629-5147
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C24837Medicare UPIN
331310CMedicare ID - Type Unspecified