Provider Demographics
NPI:1790758829
Name:PEREGO, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:PEREGO
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 2475
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-2475
Mailing Address - Country:US
Mailing Address - Phone:318-214-5770
Mailing Address - Fax:
Practice Address - Street 1:601 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6020
Practice Address - Country:US
Practice Address - Phone:318-214-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL14007R208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0280850001OtherCIGNA-GOVERMENT
LA1199729Medicaid
LAG54839Medicare UPIN
LA1199729Medicaid