Provider Demographics
NPI:1790700714
Name:MAIER, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:MAIER
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 3300
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-3300
Mailing Address - Country:US
Mailing Address - Phone:541-322-8830
Mailing Address - Fax:
Practice Address - Street 1:51600 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-9626
Practice Address - Country:US
Practice Address - Phone:541-322-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5721207Q00000X
ORMD07348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR117060Medicare PIN