Provider Demographics
NPI:1346328879
Name:BYOM, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BYOM
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 1:139 N 85TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4601
Mailing Address - Country:US
Mailing Address - Phone:414-469-1501
Mailing Address - Fax:
Practice Address - Street 1:2514 S 102ND ST
Practice Address - Street 2:STE 160
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2142
Practice Address - Country:US
Practice Address - Phone:414-255-0300
Practice Address - Fax:414-543-9601
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI02120-0154Medicare PIN
WI68015-0043Medicare PIN