Provider Demographics
NPI:1174500151
Name:WAYNE, KENNETH S (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:WAYNE
Suffix:
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 1:1005 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-6413
Mailing Address - Country:US
Mailing Address - Phone:641-682-4594
Mailing Address - Fax:641-682-2123
Practice Address - Street 1:1005 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-6413
Practice Address - Country:US
Practice Address - Phone:641-682-4594
Practice Address - Fax:641-682-2123
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32349207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2169417Medicaid
IA1174500151Medicaid
IA0169417Medicaid
IA110166527OtherRR MEDICARE
IA1169417Medicaid
IA1169417Medicaid
IA1174500151Medicaid