Basic Information
| Provider Information | |||||||||
| NPI: | 1023086931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRATHER | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 BELFORT RD | ||||||||
| Address2: | ATTEN: JULIE KAYE | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044463737 | ||||||||
| FaxNumber: | 9044463013 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W GROVE ST | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717304416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708632000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | C5928 | AR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 54158 | 01 | AR | BLUE CROSS | OTHER | 106158001 | 05 | AR | MEDICAID |