Provider Demographics
NPI:1780652644
Name:INDAHL, KENNETH G (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:INDAHL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2399 HIGHWAY 34
Mailing Address - Street 2:SUITE A-6
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-1500
Mailing Address - Country:US
Mailing Address - Phone:732-528-8223
Mailing Address - Fax:732-528-7057
Practice Address - Street 1:2399 HIGHWAY 34
Practice Address - Street 2:SUITE A-6
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-1500
Practice Address - Country:US
Practice Address - Phone:732-528-8223
Practice Address - Fax:732-528-7057
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00100900213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0599301Medicaid
NJ025228XYWMedicare PIN
NJT50807Medicare UPIN
NJ6112550001Medicare NSC