Provider Demographics
NPI:1275887770
Name:DENNISON, KUMPOL (MD)
Entity Type:Individual
Prefix:
First Name:KUMPOL
Middle Name:
Last Name:DENNISON
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 1:44 KILMARTIN CT
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-9304
Mailing Address - Country:US
Mailing Address - Phone:219-688-3950
Mailing Address - Fax:
Practice Address - Street 1:44 KILMARTIN CT
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-9304
Practice Address - Country:US
Practice Address - Phone:219-688-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071776A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100142380Medicaid
IN100142380Medicaid