Provider Demographics
NPI:1538159777
Name:MYERS, KENNETH WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WILLIAM
Last Name:MYERS
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:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:1017 ASHES DR
Practice Address - Street 2:SUITE 206
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-8352
Practice Address - Country:US
Practice Address - Phone:910-239-9584
Practice Address - Fax:910-679-4086
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000282207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1538159777Medicaid
NC2280408OtherMEDICARE PTAN
NC89126T6Medicaid
H16135Medicare UPIN