Provider Demographics
NPI:1457355083
Name:BASHOR, KENDRICK B (MD)
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:B
Last Name:BASHOR
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 1:40 MUNROE FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:MUNROE FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44262-1538
Mailing Address - Country:US
Mailing Address - Phone:330-923-0553
Mailing Address - Fax:330-923-0556
Practice Address - Street 1:96 GRAHAM RD
Practice Address - Street 2:SUITE B
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1205
Practice Address - Country:US
Practice Address - Phone:330-923-0553
Practice Address - Fax:330-923-0556
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063767B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2156876Medicaid
OHDE9283231Medicare PIN
OHF37422Medicare UPIN