Provider Demographics
NPI:1497711865
Name:FIFE, KENNETH H (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:FIFE
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 1:61 SANDY CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-2071
Mailing Address - Country:US
Mailing Address - Phone:317-457-2214
Mailing Address - Fax:
Practice Address - Street 1:61 SANDY CREEK WAY
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-2071
Practice Address - Country:US
Practice Address - Phone:317-457-2214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG153225207RI0200X
IN01030930207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100071630Medicaid
INB28403Medicare UPIN
IN264910FFFMedicare PIN