Provider Demographics
NPI:1932154275
Name:DEEB, KENNETH WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:DEEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2624 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4839
Mailing Address - Country:US
Mailing Address - Phone:972-899-6666
Mailing Address - Fax:972-899-6669
Practice Address - Street 1:5298 LAGO VISTA LN
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-1210
Practice Address - Country:US
Practice Address - Phone:214-850-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7405207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC68598Medicare UPIN