Healthcare Provider Details

I. General information

NPI: 1790148583
Provider Name (Legal Business Name): KENNETH JAMES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 MEMORIAL DR
CERES CA
95307-1827
US

IV. Provider business mailing address

900 S PINE ISLAND RD STE 800
PLANTATION FL
33324-3923
US

V. Phone/Fax

Practice location:
  • Phone: 209-541-3000
  • Fax:
Mailing address:
  • Phone: 954-315-5784
  • Fax: 954-522-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME141288
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number199796
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: