Healthcare Provider Details

I. General information

NPI: 1952515983
Provider Name (Legal Business Name): KENNETH LEMOYNE WILEY SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SAINT ROSE AVE
SAINT ROSE LA
70087-3710
US

IV. Provider business mailing address

36 CASTLE PINES DR
NEW ORLEANS LA
70131-3326
US

V. Phone/Fax

Practice location:
  • Phone: 504-466-6028
  • Fax: 504-466-6209
Mailing address:
  • Phone: 504-306-9693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD09539R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: