Provider Demographics
NPI:1851377899
Name:ANDERSON, KENNETH W (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:ANDERSON
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 1:6000 UNIVERSITY AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8203
Mailing Address - Country:US
Mailing Address - Phone:515-241-2500
Mailing Address - Fax:515-241-2505
Practice Address - Street 1:6000 UNIVERSITY AVE
Practice Address - Street 2:STE 100
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8203
Practice Address - Country:US
Practice Address - Phone:515-241-2500
Practice Address - Fax:515-241-2505
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19114208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1851377899Medicaid
IA370033541OtherRR MEDICARE
IA0098137Medicaid
IA719260223Medicare PIN
IA370033541OtherRR MEDICARE
IAA01051Medicare UPIN