Provider Demographics
NPI:1902838824
Name:SELLS, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SELLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MAIN STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-0294
Mailing Address - Country:US
Mailing Address - Phone:304-752-3400
Mailing Address - Fax:304-752-3400
Practice Address - Street 1:533 MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3809
Practice Address - Country:US
Practice Address - Phone:304-752-3400
Practice Address - Fax:304-752-8138
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G10695Medicare UPIN