Provider Demographics
NPI:1710186945
Name:RICHARDS, KENNETH ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROY
Last Name:RICHARDS
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 1:104 LAKEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-3922
Mailing Address - Country:US
Mailing Address - Phone:870-415-8341
Mailing Address - Fax:
Practice Address - Street 1:1003 FRED LAGRONE DR
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-4546
Practice Address - Country:US
Practice Address - Phone:870-364-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE8766208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR203261001Medicaid