Provider Demographics
NPI:1912996158
Name:VANDERVOORT, KENNETH LUCKIE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LUCKIE
Last Name:VANDERVOORT
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 1:731 LEIGHTON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-5762
Mailing Address - Country:US
Mailing Address - Phone:256-236-4121
Mailing Address - Fax:256-237-5254
Practice Address - Street 1:731 LEIGHTON AVE STE 300
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-5762
Practice Address - Country:US
Practice Address - Phone:256-236-4121
Practice Address - Fax:256-237-5254
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00013298207X00000X
ALMD.13298207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000017436Medicaid
AL051017436OtherBLUE SHIELD
AL000017436Medicare PIN
AL000017436Medicaid