Provider Demographics
NPI:1710968060
Name:GRIFFITH, KENDALL M (MD)
Entity Type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:M
Last Name:GRIFFITH
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 1:717 W LEE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLET
Mailing Address - State:GA
Mailing Address - Zip Code:30415-6225
Mailing Address - Country:US
Mailing Address - Phone:340-643-5989
Mailing Address - Fax:
Practice Address - Street 1:1058 BERMUDA RUN
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0858
Practice Address - Country:US
Practice Address - Phone:912-243-9274
Practice Address - Fax:912-341-6513
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA68903207RI0011X
FLME73855207RI0011X
VI1191207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VIH55290Medicare UPIN
VI0020780Medicare PIN