Provider Demographics
NPI:1659372175
Name:KIMMEL, KENNETH K (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
Last Name:KIMMEL
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 1:3310 CLINTON PARKWAY CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-2629
Mailing Address - Country:US
Mailing Address - Phone:785-842-7200
Mailing Address - Fax:785-842-9397
Practice Address - Street 1:3310 CLINTON PARKWAY CT
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-2629
Practice Address - Country:US
Practice Address - Phone:785-842-7200
Practice Address - Fax:785-842-9397
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-17863174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2051620402Medicaid
KS2051620402Medicaid
KS057664Medicare ID - Type Unspecified