Provider Demographics
NPI:1942246046
Name:FENNELL, KENNETH OWEN (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:OWEN
Last Name:FENNELL
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24850 SE STARK
Mailing Address - Street 2:STE 150
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-491-0714
Mailing Address - Fax:503-674-2834
Practice Address - Street 1:24850 SE STARK
Practice Address - Street 2:STE 150
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-491-0714
Practice Address - Fax:503-674-2834
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16170208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics