Provider Demographics
NPI:1598849903
Name:DISTLER, KENNETH W (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:DISTLER
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 1:2130 MARSHALL CT
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3351
Mailing Address - Country:US
Mailing Address - Phone:989-799-0600
Mailing Address - Fax:989-799-6080
Practice Address - Street 1:2130 MARSHALL CT
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3351
Practice Address - Country:US
Practice Address - Phone:989-799-0600
Practice Address - Fax:989-799-6080
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKD046952174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1681561Medicaid
MIKD046952OtherLICENSE
MIE26233Medicare UPIN
MI1681561Medicaid