Provider Demographics
NPI:1801834130
Name:KETNER, JOHN MARSHALL (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARSHALL
Last Name:KETNER
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 1:5624 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1926
Mailing Address - Country:US
Mailing Address - Phone:248-674-9664
Mailing Address - Fax:248-674-5409
Practice Address - Street 1:5624 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1926
Practice Address - Country:US
Practice Address - Phone:248-674-9664
Practice Address - Fax:248-674-5409
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK007570208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI107304OtherCARE CHOICES
MI2856OtherCAPE ID
MIE26093OtherHEALTH ALLIANCE PLAN ID
MI5630206OtherBLUE CROSS BLUE SHIELD ID
MI2125962Medicaid
MI4621708005OtherCIGNA ID
MI5630206Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
MIE26093OtherHEALTH ALLIANCE PLAN ID