Healthcare Provider Details

I. General information

NPI: 1295798825
Provider Name (Legal Business Name): KENNETH R CLOSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2722 OSLER BLVD
BRYAN TX
77802-2517
US

IV. Provider business mailing address

2722 OSLER BLVD
BRYAN TX
77802-2517
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-8291
  • Fax: 979-774-7871
Mailing address:
  • Phone: 979-776-8291
  • Fax: 979-774-7871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME171890
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberL3942
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberL3942
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: