Provider Demographics
NPI:1437173051
Name:PITERS, KENNETH MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:PITERS
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 6671
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95406-0671
Mailing Address - Country:US
Mailing Address - Phone:707-544-7331
Mailing Address - Fax:707-623-9409
Practice Address - Street 1:1383 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1187
Practice Address - Country:US
Practice Address - Phone:707-544-7331
Practice Address - Fax:707-623-9409
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29348207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G293481Medicaid
CAA44020Medicare UPIN
CA00G293481Medicaid