Provider Demographics
NPI:1427000967
Name:KIDD, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:KIDD
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 1:1305 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1503
Mailing Address - Country:US
Mailing Address - Phone:262-473-4548
Mailing Address - Fax:262-472-7691
Practice Address - Street 1:1305 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1503
Practice Address - Country:US
Practice Address - Phone:262-473-4548
Practice Address - Fax:262-472-7691
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23985-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI142700967Medicaid
WI142700967Medicaid
WI080181490Medicare PIN
WI000954375Medicare PIN
WI213OtherDEAN HEALTH INSURANCE
WI000954375Medicare PIN