Provider Demographics
NPI:1871504290
Name:CAPONE, KENNETH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:CAPONE
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 1:201 SAINT ANN DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3219
Mailing Address - Country:US
Mailing Address - Phone:985-626-1717
Mailing Address - Fax:
Practice Address - Street 1:201 SAINT ANN DR
Practice Address - Street 2:SUITE B
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3219
Practice Address - Country:US
Practice Address - Phone:985-626-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014719208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1312151Medicaid