Provider Demographics
NPI:1255311361
Name:MCCANN, KENNETH JAMES (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:MCCANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 PLEASANT ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1416
Mailing Address - Country:US
Mailing Address - Phone:515-241-4311
Mailing Address - Fax:515-241-4320
Practice Address - Street 1:1215 PLEASANT ST
Practice Address - Street 2:SUITE 303
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1416
Practice Address - Country:US
Practice Address - Phone:515-241-4311
Practice Address - Fax:515-241-4320
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO00617208000000X
IA3772208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDO00617OtherLICENSE
RIKM67872Medicaid
RI007059639Medicare PIN