Provider Demographics
NPI:1508856303
Name:BURKHART, KENNETH D (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:BURKHART
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 1:300 W BROADWAY
Mailing Address - Street 2:STE 6
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503
Mailing Address - Country:US
Mailing Address - Phone:712-325-1990
Mailing Address - Fax:712-325-0288
Practice Address - Street 1:300 W BROADWAY
Practice Address - Street 2:STE 6
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:712-325-1990
Practice Address - Fax:712-325-0288
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0188946Medicaid
161803OtherMEDICARE FQHC
IA2183632Medicaid
IAI10402Medicare ID - Type Unspecified
161803OtherMEDICARE FQHC
IA0188946Medicaid