Provider Demographics
NPI:1922117191
Name:OWEN, KENNETH D JR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:OWEN
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 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-335-4400
Mailing Address - Fax:704-358-4400
Practice Address - Street 1:1900 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1822
Practice Address - Country:US
Practice Address - Phone:704-302-8400
Practice Address - Fax:704-358-4451
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34700207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN34700Medicaid
NC5905027Medicaid
NC1922117191Medicaid
NCF11006Medicare UPIN
SCN34700Medicaid
NC5905027Medicaid