Provider Demographics
NPI:1053479154
Name:COLTON, KENNETH L (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:COLTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-3628
Mailing Address - Country:US
Mailing Address - Phone:734-522-7000
Mailing Address - Fax:734-522-7012
Practice Address - Street 1:400 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3628
Practice Address - Country:US
Practice Address - Phone:734-522-7000
Practice Address - Fax:734-522-7012
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009187207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080H225910OtherBCN PROVIDER NUMBER
MI4331440Medicaid
MI080H225910OtherBCBS PROVIDER NUMBER
MI080H225910OtherBCN PROVIDER NUMBER
MIOP23120Medicare PIN
MIOP23120Medicare ID - Type Unspecified