Healthcare Provider Details

I. General information

NPI: 1932154275
Provider Name (Legal Business Name): KENNETH WAYNE DEEB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5298 LAGO VISTA LN
FRISCO TX
75034-1210
US

IV. Provider business mailing address

2624 LONG PRAIRIE RD
FLOWER MOUND TX
75022-4839
US

V. Phone/Fax

Practice location:
  • Phone: 214-850-3791
  • Fax:
Mailing address:
  • Phone: 972-899-6666
  • Fax: 972-899-6669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH7405
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: