Provider Demographics
NPI:1902819543
Name:SCHULTZ, KENNETH JOHN (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 SADDLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-3375
Mailing Address - Country:US
Mailing Address - Phone:816-304-1122
Mailing Address - Fax:816-224-9273
Practice Address - Street 1:3420 SADDLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-3375
Practice Address - Country:US
Practice Address - Phone:816-304-1122
Practice Address - Fax:816-224-9273
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000753213E00000X
KS12-00290213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
114053OtherBCBS OF KS
25031037OtherBCBS OF KANSAS CITY
KS1003025406Medicaid
114053OtherBCBS OF KS
25031037OtherBCBS OF KANSAS CITY
0008670Medicare ID - Type Unspecified
0008670BMedicare ID - Type Unspecified