Provider Demographics
NPI:1780656561
Name:ELMASSIAN, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:ELMASSIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 HAMILTON RD STE 102E
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1941
Mailing Address - Country:US
Mailing Address - Phone:517-482-2118
Mailing Address - Fax:517-482-6280
Practice Address - Street 1:2900 COLLINS RD # 106
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8394
Practice Address - Country:US
Practice Address - Phone:517-482-2118
Practice Address - Fax:517-482-6280
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKE007148207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1320111Medicaid
E95674Medicare UPIN
OC36012007Medicare ID - Type Unspecified