Provider Demographics
NPI:1295809275
Name:WESTON, KENNETH G (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:WESTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:303 N KEENE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7193
Mailing Address - Country:US
Mailing Address - Phone:573-449-0808
Mailing Address - Fax:573-442-1331
Practice Address - Street 1:303 N KEENE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7193
Practice Address - Country:US
Practice Address - Phone:573-449-0808
Practice Address - Fax:573-442-1331
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR4C65207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
01-9492OtherUNITED HEALTH CARE
MO201483914Medicaid
4369507OtherAETNA
MO25787OtherBLUE CROSS BLUE SHIELD
102652OtherHEALTHLINK
54599OtherGROUP HEALTH PLANS
4369507OtherAETNA
MO201483914Medicaid