Provider Demographics
NPI:1871669994
Name:HARPER, KENNETH WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WESLEY
Last Name:HARPER
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 856
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-0856
Mailing Address - Country:US
Mailing Address - Phone:678-418-2120
Mailing Address - Fax:678-418-2936
Practice Address - Street 1:6000 HILLANDALE DR STE 100
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4860
Practice Address - Country:US
Practice Address - Phone:678-418-2120
Practice Address - Fax:678-418-2936
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00794912CMedicaid
GA035182OtherSTATE LICENSE
GA035182OtherSTATE LICENSE
GA00794912CMedicaid