Provider Demographics
NPI:1396738266
Name:CARR, KENNETH W (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:CARR
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:PO BOX 1064
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-1064
Mailing Address - Country:US
Mailing Address - Phone:731-587-5353
Mailing Address - Fax:
Practice Address - Street 1:115 MOUNT PELIA RD
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3315
Practice Address - Country:US
Practice Address - Phone:731-587-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000009324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN31659301Medicare PIN
TNB03136Medicare UPIN