Provider Demographics
NPI:1902893183
Name:MARRIOTT, KENNETH ARMISTICE III (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ARMISTICE
Last Name:MARRIOTT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WATERS EDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-1021
Mailing Address - Country:US
Mailing Address - Phone:210-305-3505
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8121207P00000X
VA0101236229207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB144438Medicare PIN
ILOTH000Medicare UPIN