Provider Demographics
NPI:1881608842
Name:DACEY, KENNETH A (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:DACEY
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 1:7154 N UNIVERSITY DR # 316
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2916
Mailing Address - Country:US
Mailing Address - Phone:954-720-3188
Mailing Address - Fax:
Practice Address - Street 1:7171 N UNIVERSITY DR STE 300
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2902
Practice Address - Country:US
Practice Address - Phone:954-720-3188
Practice Address - Fax:954-586-2589
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53311207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263437600Medicaid
D21178Medicare UPIN