Provider Demographics
NPI:1437124633
Name:BALLEW, KENNETH KYLE (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:KYLE
Last Name:BALLEW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:K.
Other - Middle Name:KYLE
Other - Last Name:BALLEW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:7125 NEW SANGER AVE STE 502
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-4054
Mailing Address - Country:US
Mailing Address - Phone:254-732-2224
Mailing Address - Fax:254-732-2226
Practice Address - Street 1:7125 NEW SANGER AVE STE 502
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-4054
Practice Address - Country:US
Practice Address - Phone:254-732-2224
Practice Address - Fax:254-732-2226
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0879213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8JG027OtherBC/BS OF TEXAS
TX1122319Medicaid
TX480028450OtherMEDICARE RAILROAD
TX480028450OtherMEDICARE RAILROAD
TX112231904Medicaid