Provider Demographics
NPI:1417956525
Name:PECHMAN, KENNETH JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOSEPH
Last Name:PECHMAN
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-683-5278
Mailing Address - Fax:920-686-9674
Practice Address - Street 1:2806 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6717
Practice Address - Country:US
Practice Address - Phone:920-498-7546
Practice Address - Fax:920-569-4129
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-02-23
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
WI24239020174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417956525Medicaid
WIAP9795418OtherDEA
WI24239020OtherWI STATE LICENSE #
WIP00292662OtherRAILROAD MEDICARE
WI1417956525Medicaid
WI000617140Medicare PIN