Provider Demographics
NPI:1811045404
Name:PODELL, KENNETH (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PODELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 FANNIN ST STE 1840
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2734
Mailing Address - Country:US
Mailing Address - Phone:713-441-3780
Mailing Address - Fax:713-790-6468
Practice Address - Street 1:6560 FANNIN ST STE 1840
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2734
Practice Address - Country:US
Practice Address - Phone:713-441-3780
Practice Address - Fax:713-790-6468
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010102942084P0800X
TX363512084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KP010294OtherCHAMPUS-CHAMPUS
TX310963902Medicaid
KP010294OtherCOMMERCIAL-COMMERCIAL NUMBER
MIPHD888810Medicaid
7509104450OtherBLUE CROSS-BLUE CROSS
R07562Medicare UPIN
TX310963902Medicaid