Provider Demographics
NPI:1831186709
Name:GATI, KENNETH G (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:GATI
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 10730
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-0028
Mailing Address - Country:US
Mailing Address - Phone:870-862-1144
Mailing Address - Fax:870-864-0782
Practice Address - Street 1:2700 VINE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-6700
Practice Address - Country:US
Practice Address - Phone:870-862-1144
Practice Address - Fax:870-864-0782
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2039174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139668001Medicaid
AR0424120002OtherDMEPOS
AR200038438OtherUNITED /RAILROAD MEDICARE
AR18697000000OtherQUALCHOICE
AR200038438OtherUNITED /RAILROAD MEDICARE
ARH11377Medicare UPIN