Provider Demographics
NPI:1942252952
Name:DEMIRJIAN, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:DEMIRJIAN
Suffix:
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 1:222 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1852
Mailing Address - Country:US
Mailing Address - Phone:629-255-3486
Mailing Address - Fax:
Practice Address - Street 1:325 OLD PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-4493
Practice Address - Country:US
Practice Address - Phone:629-255-2072
Practice Address - Fax:629-255-4161
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3053986Medicaid
TN3053982Medicare PIN
TNB92561Medicare UPIN
TN3053986Medicaid
TN2654533OtherCIGNA
TNP2639991OtherFIRST HEALTH
TN080131910OtherR/R MEDICARE
TN3053986Medicaid
TNB92561OtherHEALTHSPRING
TNB92561Medicare UPIN