Provider Demographics
NPI:1891792545
Name:CIOLLI, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CIOLLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8637 FREDERICKSBURG RD
Mailing Address - Street 2:#360
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1285
Mailing Address - Country:US
Mailing Address - Phone:210-949-4179
Mailing Address - Fax:210-617-4075
Practice Address - Street 1:6218 NW LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-3306
Practice Address - Country:US
Practice Address - Phone:210-523-1411
Practice Address - Fax:210-523-9307
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C23856Medicare UPIN
TX87M871Medicare PIN