Provider Demographics
NPI:1568426047
Name:JANSON, KENNETH L (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:JANSON
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 1:4443 LYONS RD STE 211
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4388
Mailing Address - Country:US
Mailing Address - Phone:954-405-0501
Mailing Address - Fax:954-301-8501
Practice Address - Street 1:4443 LYONS RD STE 211
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4388
Practice Address - Country:US
Practice Address - Phone:954-405-0501
Practice Address - Fax:954-301-8501
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-043934208800000X
FLME1116472083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-043934Medicaid
ILC38241Medicare UPIN
IL036-043934Medicaid