Provider Demographics
NPI:1548261720
Name:FRANKLIN, KENNETH J (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:FRANKLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13320 N BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-1514
Mailing Address - Country:US
Mailing Address - Phone:269-649-2012
Mailing Address - Fax:269-649-3752
Practice Address - Street 1:13320 N BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-1514
Practice Address - Country:US
Practice Address - Phone:269-649-2012
Practice Address - Fax:269-649-3752
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKF059211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4388855Medicaid
MIH58738Medicare UPIN
MIOMO4700Medicare ID - Type Unspecified