Provider Demographics
NPI:1124225479
Name:IVERSON, KENNETH CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CHARLES
Last Name:IVERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:800 ROSE ST # C236
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0293
Mailing Address - Country:US
Mailing Address - Phone:859-257-5405
Mailing Address - Fax:859-257-5096
Practice Address - Street 1:740 SOUTH LIMESTONE KENTUCKY CLINIC C300
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0293
Practice Address - Country:US
Practice Address - Phone:859-257-5405
Practice Address - Fax:859-257-5096
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48196207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100357020Medicaid
KY7100357020Medicaid
KYK183790Medicare PIN