Provider Demographics
NPI:1912917865
Name:WILLEFORD, KENNETH LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:WILLEFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10 DOCTORS CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4089
Mailing Address - Country:US
Mailing Address - Phone:910-755-6060
Mailing Address - Fax:910-755-6061
Practice Address - Street 1:10 DOCTORS CIR
Practice Address - Street 2:SUITE 2
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4089
Practice Address - Country:US
Practice Address - Phone:910-755-6060
Practice Address - Fax:910-755-6061
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36621208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8987642Medicaid
NC016UXOtherBCBS NC
NCE99918Medicare UPIN
NC2186636DMedicare ID - Type Unspecified