Provider Demographics
NPI:1992824007
Name:POWELL, KENNETH ANGUS (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ANGUS
Last Name:POWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:2700 RIVERSIDE AVE STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-8233
Practice Address - Country:US
Practice Address - Phone:904-265-7755
Practice Address - Fax:904-265-7754
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10548208100000X, 2081P2900X
FLOS 10548208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001324200Medicaid
FLCF880ZMedicare PIN