Provider Demographics
NPI:1184668857
Name:KETCHAM, WILLIAM D (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:D
Last Name:KETCHAM
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 1:800 E 20TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3859
Mailing Address - Country:US
Mailing Address - Phone:307-634-7711
Mailing Address - Fax:
Practice Address - Street 1:800 E 20TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3859
Practice Address - Country:US
Practice Address - Phone:307-634-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6803A2085R0202X
CO409722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY311699OtherBCBS OF WYOMING CRG
CO22971211Medicaid
WY311700OtherBCBS OF WYOMING MRI
WY311699OtherBCBS OF WYOMING CRG
H73010Medicare UPIN
CO483508Medicare ID - Type UnspecifiedCO MEDICARE NUMBER
CO22971211Medicaid