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General NPI Number Information
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NPI Number | 1205800596
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Entity Type | Individual
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Provider Name | KENNETH M SAMPLE M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/14/2006
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Last Update Date | 02/12/2020
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Provider Practice Location Address
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Address Line | 100 BREWSTER BLVD
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City | CAMP LEJEUNE
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State | NC
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Zip | 28547-2575
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Country | US
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Telephone | 910-450-4760
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Fax |
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Provider Business Mailing Address
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Address Line | 897 LYNCHBURG DR
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City | JACKSONVILLE
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State | NC
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Zip | 28546-6018
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Country | US
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Telephone | 910-381-6942
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 01053054A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 0101253264
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 24465
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License Number State | KY
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