Provider Demographics
NPI:1902814361
Name:DAUGHTREY, KENNETH RAY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAY
Last Name:DAUGHTREY
Suffix:JR
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 157A
Mailing Address - Street 2:
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-0157
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:601-351-8301
Practice Address - Street 1:3550 HIGHWAY 468 W
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-5529
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:601-351-8301
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS115162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04475520Medicaid
MS04475520Medicaid
MS080261602Medicare ID - Type Unspecified