Provider Demographics
NPI:1245236124
Name:HAUSWALD, KENNETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:HAUSWALD
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 1:1505 SW CARY PKWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-6219
Mailing Address - Country:US
Mailing Address - Phone:919-367-2580
Mailing Address - Fax:
Practice Address - Street 1:1505 SW CARY PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6219
Practice Address - Country:US
Practice Address - Phone:919-367-2580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2009-03-03
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
NC17366208600000X
KY16406208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0385104Medicaid
WV3810002481Medicaid
KY64164064Medicaid
KY64164064Medicaid
KY1902501Medicare ID - Type Unspecified
WV3810002481Medicaid