Provider Demographics
NPI:1851398713
Name:MANN, KENNETH E (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:MANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3937 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3649
Mailing Address - Country:US
Mailing Address - Phone:800-354-1088
Mailing Address - Fax:314-631-4491
Practice Address - Street 1:3937 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3649
Practice Address - Country:US
Practice Address - Phone:816-676-0625
Practice Address - Fax:816-676-0627
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1157932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200070690AMedicaid
MO283829231Medicaid
AR135713003Medicaid
OK249602006Medicare PIN
AR135713003Medicaid
MOQ28C254Medicare ID - Type UnspecifiedMEDICARE KC #
MO283829231Medicaid