Provider Demographics
NPI:1013987593
Name:HAMILTON, KENNETH WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:HAMILTON
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 1:909 SOUTHEAST PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3600
Mailing Address - Country:US
Mailing Address - Phone:817-238-0735
Mailing Address - Fax:817-238-7327
Practice Address - Street 1:909 SOUTHEAST PKWY STE 105
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3600
Practice Address - Country:US
Practice Address - Phone:817-238-0735
Practice Address - Fax:817-238-7327
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4181207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101799803Medicaid
TX101799802Medicaid
TX101799802Medicaid
TX101799803Medicaid
TX82G724Medicare ID - Type Unspecified