Provider Demographics
NPI:1285626804
Name:MARTIN, KENNETH J (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:408 HELEN CIR
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1222
Mailing Address - Country:US
Mailing Address - Phone:215-877-2555
Mailing Address - Fax:215-877-0240
Practice Address - Street 1:7331 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151
Practice Address - Country:US
Practice Address - Phone:215-877-2555
Practice Address - Fax:215-877-0240
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002881L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0060738000OtherIBC
PA11940OtherHEALTH PARTNERS PA
PA31875OtherKEYSTONE MERCY HEALTH PLA
PA0104650501OtherAMERICHOICE OF PA
PA1480OtherBRAVO ELDERHEALTH
PA175404OtherBC BS OF PA
PA0010465050004Medicaid
PA0060738000OtherIBC
PA0104650501OtherAMERICHOICE OF PA
PA31875OtherKEYSTONE MERCY HEALTH PLA