Provider Demographics
NPI:1801967674
Name:PERES, KENNETH E (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:PERES
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 1:2311 HIGHWAY 15 S
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-7071
Mailing Address - Country:US
Mailing Address - Phone:662-779-0119
Mailing Address - Fax:
Practice Address - Street 1:2311 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-7071
Practice Address - Country:US
Practice Address - Phone:662-779-0119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS175182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125174Medicaid
MS00125174Medicaid