Provider Demographics
NPI:1114066065
Name:EDWARDS, KENNETH LEE (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3461 WARRENSVILLE CENTER ROAD
Mailing Address - Street 2:303
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5227
Mailing Address - Country:US
Mailing Address - Phone:216-752-0727
Mailing Address - Fax:
Practice Address - Street 1:3461 WARRENSVILLE CENTER ROAD
Practice Address - Street 2:303
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5227
Practice Address - Country:US
Practice Address - Phone:216-752-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2580-E213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0753297Medicaid
OH000000116438OtherANTHEM BC & BS
OH000000116438OtherANTHEM BC & BS
OH0649151Medicare PIN