Provider Demographics
NPI:1538247879
Name:O'NEAL, KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:O'NEAL
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 1:1215 TUSCANY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-3488
Mailing Address - Country:US
Mailing Address - Phone:770-307-1880
Mailing Address - Fax:770-307-1889
Practice Address - Street 1:1412 MILSTEAD AVE NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:770-918-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060951207R00000X
LA309691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA759558453AMedicaid
GAG13631Medicare UPIN
GA759558453AMedicaid