Provider Demographics
NPI:1275513756
Name:ANDERSON, KENNETH R (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:ANDERSON
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 1:1200 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARITON
Mailing Address - State:IA
Mailing Address - Zip Code:50049-1210
Mailing Address - Country:US
Mailing Address - Phone:641-774-8103
Mailing Address - Fax:641-774-8087
Practice Address - Street 1:1200 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARITON
Practice Address - State:IA
Practice Address - Zip Code:50049-1210
Practice Address - Country:US
Practice Address - Phone:641-774-8103
Practice Address - Fax:641-774-8087
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4193557Medicaid
IA1275513756OtherWELLMARK
IA40870OtherBCBS
IA110153091OtherTRAVELERS MEDICARE
IA40871OtherBCBS
IA1275513756Medicaid
IA5193557Medicaid
IA40870Medicare PIN
IA40871OtherBCBS
IA40870OtherBCBS
IA40870Medicare ID - Type Unspecified