Provider Demographics
NPI:1265411086
Name:CLONINGER, KENNETH KYLE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:KYLE
Last Name:CLONINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:808 SCHENCK ST
Mailing Address - Street 2:CLECO PRIMARY CARE NETWORK
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3934
Mailing Address - Country:US
Mailing Address - Phone:704-480-9344
Mailing Address - Fax:704-484-3260
Practice Address - Street 1:808 SCHENCK ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3934
Practice Address - Country:US
Practice Address - Phone:704-480-9344
Practice Address - Fax:704-484-3260
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8923031Medicaid
B08086Medicare UPIN
NCNCA766AMedicare PIN
NC2226721CMedicare PIN