Provider Demographics
NPI:1770664138
Name:ABBOTT, KENNETH W (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:ABBOTT
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:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3200
Mailing Address - Fax:574-296-3544
Practice Address - Street 1:2222 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1420
Practice Address - Country:US
Practice Address - Phone:574-294-3030
Practice Address - Fax:574-294-3544
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0102595A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112470Medicaid
IN180041763OtherRAILROAD MEDICARE
IN180041763OtherRAILROAD MEDICARE
IN233910BMedicare ID - Type Unspecified