Provider Demographics
NPI:1962498337
Name:STANLEY, KENNETH JERMAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JERMAINE
Last Name:STANLEY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10223 BROADWAY ST
Mailing Address - Street 2:SUITE P335
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7880
Mailing Address - Country:US
Mailing Address - Phone:713-436-8501
Mailing Address - Fax:713-436-8563
Practice Address - Street 1:10100 BROADWAY ST
Practice Address - Street 2:SUITE 110
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8425
Practice Address - Country:US
Practice Address - Phone:713-436-8501
Practice Address - Fax:713-436-8563
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL2014207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F4480Medicare PIN
TXH51088Medicare UPIN
TX8G2651Medicare PIN