Provider Demographics
NPI:1730103730
Name:MAYNARD, KENNETH MITCHUM (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MITCHUM
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 SOUTHFIELD DR
Mailing Address - Street 2:SUITE 1370
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4498
Mailing Address - Country:US
Mailing Address - Phone:317-837-5571
Mailing Address - Fax:317-837-5580
Practice Address - Street 1:1045 WYATT WAY
Practice Address - Street 2:
Practice Address - City:LIZTON
Practice Address - State:IN
Practice Address - Zip Code:46149-9583
Practice Address - Country:US
Practice Address - Phone:317-994-6600
Practice Address - Fax:317-994-6605
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000836A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200932990Medicaid
IN200932990Medicaid
INM400038403Medicare PIN
IN342100BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER