Provider Demographics
NPI:1275565392
Name:WU, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WU
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:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-0039
Mailing Address - Country:US
Mailing Address - Phone:732-281-3590
Mailing Address - Fax:732-281-0054
Practice Address - Street 1:15 VERSAILLES BLVD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-5133
Practice Address - Country:US
Practice Address - Phone:732-281-3590
Practice Address - Fax:732-281-0054
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06591200208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG54246Medicare UPIN
NJ955009Medicare ID - Type UnspecifiedMEDICAR PROVIDER NUMBER