Provider Demographics
NPI:1467494013
Name:IMBODEN, KENNETH JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
Last Name:IMBODEN
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 1:153 W GENESEE ST
Mailing Address - Street 2:UPPER LEVEL
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-1528
Mailing Address - Country:US
Mailing Address - Phone:315-687-5100
Mailing Address - Fax:315-687-0252
Practice Address - Street 1:153 W GENESEE ST
Practice Address - Street 2:UPPER LEVEL
Practice Address - City:CHITTENANGO
Practice Address - State:NY
Practice Address - Zip Code:13037-1528
Practice Address - Country:US
Practice Address - Phone:315-687-5100
Practice Address - Fax:315-687-0252
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130809207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine