Provider Demographics
NPI:1952515983
Name:WILEY, KENNETH LEMOYNE SR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEMOYNE
Last Name:WILEY
Suffix:SR
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 1:36 CASTLE PINES DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70131-3326
Mailing Address - Country:US
Mailing Address - Phone:504-306-9693
Mailing Address - Fax:
Practice Address - Street 1:105 SAINT ROSE AVE
Practice Address - Street 2:
Practice Address - City:SAINT ROSE
Practice Address - State:LA
Practice Address - Zip Code:70087-3710
Practice Address - Country:US
Practice Address - Phone:504-466-6028
Practice Address - Fax:504-466-6209
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD09539R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1965669Medicaid
LA5C406Medicare ID - Type Unspecified
LA1965669Medicaid