Provider Demographics
NPI:1629053681
Name:KENDZIERSKI, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KENDZIERSKI
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 1:3440 ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-4343
Mailing Address - Country:US
Mailing Address - Phone:419-340-1289
Mailing Address - Fax:419-972-4203
Practice Address - Street 1:3440 ISLAND AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614
Practice Address - Country:US
Practice Address - Phone:419-340-1289
Practice Address - Fax:419-972-4203
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.080641207QA0401X
OH35. 080641208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104719902Medicaid
OH2426860Medicaid
OH605424OtherBUCKEYE
OH000000213037OtherANTHEM
OH080139052OtherRAILROAD MEDICARE
OH01973OtherPARAMOUNT
OH2426860Medicaid
OH01973OtherPARAMOUNT