Provider Demographics
NPI:1023086931
Name:PRATHER, KENNETH C (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:PRATHER
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 1:5220 BELFORT RD
Mailing Address - Street 2:ATTEN: JULIE KAYE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6017
Mailing Address - Country:US
Mailing Address - Phone:904-446-3737
Mailing Address - Fax:904-446-3013
Practice Address - Street 1:700 W GROVE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4416
Practice Address - Country:US
Practice Address - Phone:870-863-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5928208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR54158OtherBLUE CROSS
AR106158001Medicaid
ARB90494Medicare UPIN
ARB90494Medicare UPIN
AR10044077Medicare ID - Type UnspecifiedRAILROAD MEDICARE