Provider Demographics
NPI:1386654986
Name:ANDERSEN, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:ANDERSEN
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-6000
Mailing Address - Fax:515-643-6001
Practice Address - Street 1:5615 NW 86TH ST
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1738
Practice Address - Country:US
Practice Address - Phone:515-643-6000
Practice Address - Fax:515-643-6001
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3020362Medicaid
IA23739Medicare ID - Type Unspecified
IA3020362Medicaid