Provider Demographics
NPI:1619075868
Name:MAH, KENNETH KS (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:KS
Last Name:MAH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14355 SW ALLEN BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-4700
Mailing Address - Country:US
Mailing Address - Phone:503-643-1737
Mailing Address - Fax:
Practice Address - Street 1:14355 SW ALLEN BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4700
Practice Address - Country:US
Practice Address - Phone:503-643-1737
Practice Address - Fax:503-643-4926
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP144213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000SGBGHMedicare ID - Type Unspecified
T67869Medicare UPIN
OR0000SGBGHMedicare PIN