Provider Demographics
NPI:1972550333
Name:DEGRAAF, KENNETH MARK (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MARK
Last Name:DEGRAAF
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 1:13927 MARGO AVE
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-1341
Mailing Address - Country:US
Mailing Address - Phone:941-759-0073
Mailing Address - Fax:
Practice Address - Street 1:14000 FIVAY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7103
Practice Address - Country:US
Practice Address - Phone:727-819-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85861207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B48393Medicare UPIN