Provider Demographics
NPI:1659347086
Name:TREADWELL, KENNETH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:TREADWELL
Suffix:JR
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 1:1387 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1442
Mailing Address - Country:US
Mailing Address - Phone:973-372-1441
Mailing Address - Fax:973-372-6019
Practice Address - Street 1:1387 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-1442
Practice Address - Country:US
Practice Address - Phone:973-372-1441
Practice Address - Fax:973-372-6019
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03828700207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3369803Medicaid
NJ25MA03828700OtherSTATE LIC NR
NJ25MA03828700OtherSTATE LIC NR
NJ3369803Medicaid