Provider Demographics
NPI:1740378785
Name:RICHARDS, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MO
Mailing Address - Zip Code:63556-1316
Mailing Address - Country:US
Mailing Address - Phone:660-265-4456
Mailing Address - Fax:660-265-4627
Practice Address - Street 1:210 N MARKET ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MO
Practice Address - Zip Code:63556-1316
Practice Address - Country:US
Practice Address - Phone:660-265-4456
Practice Address - Fax:660-265-4627
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO248220519Medicaid
MO120670006Medicare PIN
MOF19676Medicare UPIN