Basic Information
| Provider Information | |||||||||
| NPI: | 1477649754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORSEY | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11511 SHADOW CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775847298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 560 MEYERLAND PLAZA MALL | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770961615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134421615 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | K1811 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | K1811 | TX | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 102504106 | 05 | TX | MEDICAID | 102504101 | 05 | TX | MEDICAID | 102504104 | 05 | TX | MEDICAID |