Provider Demographics
NPI:1437402013
Name:KENNETH D WARREN DPM PLLC
Entity Type:Organization
Organization Name:KENNETH D WARREN DPM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-577-7754
Mailing Address - Street 1:2 BERRY CT
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6812
Mailing Address - Country:US
Mailing Address - Phone:207-985-9888
Mailing Address - Fax:207-985-3488
Practice Address - Street 1:2 BERRY CT
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6812
Practice Address - Country:US
Practice Address - Phone:207-985-9888
Practice Address - Fax:207-985-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1880213ES0103X
ME1084261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty