Healthcare Provider Details

I. General information

NPI: 1740504083
Provider Name (Legal Business Name): KENNETH W STATHOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N 25TH AVE
HOLLYWOOD FL
33020-3405
US

IV. Provider business mailing address

1111 N 25TH AVE
HOLLYWOOD FL
33020-3405
US

V. Phone/Fax

Practice location:
  • Phone: 954-921-6494
  • Fax:
Mailing address:
  • Phone: 954-921-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: