Provider Demographics
NPI:1780655167
Name:KENDRICK, LEE W (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:W
Last Name:KENDRICK
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 1:2215 WILDWOOD AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-5089
Mailing Address - Country:US
Mailing Address - Phone:501-753-2424
Mailing Address - Fax:501-753-2733
Practice Address - Street 1:2215 WILDWOOD AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-5089
Practice Address - Country:US
Practice Address - Phone:501-753-2424
Practice Address - Fax:501-753-2733
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7713174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128293001Medicaid
ARG22288Medicare UPIN
AR5J900Medicare ID - Type Unspecified