Provider Demographics
NPI:1154334696
Name:AVERY, KENNETH BURTON (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BURTON
Last Name:AVERY
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 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE G500
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1262
Mailing Address - Fax:304-691-1666
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:SUITE G500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-691-1262
Practice Address - Fax:304-691-1666
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00295213E00000X
WV00357213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2107501000Medicaid
KY80000060Medicaid
WV4030923Medicare PIN
KY00636001Medicare PIN
KY80000060Medicaid