Provider Demographics
NPI:1922104835
Name:IYAMU, KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:IYAMU
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 1:1700 N MCMULLEN BOOTH RD
Mailing Address - Street 2:D1
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2130
Mailing Address - Country:US
Mailing Address - Phone:727-669-3800
Mailing Address - Fax:727-669-5600
Practice Address - Street 1:1700 N MCMULLEN BOOTH RD
Practice Address - Street 2:D1
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-2130
Practice Address - Country:US
Practice Address - Phone:727-669-3800
Practice Address - Fax:727-669-5600
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0090707207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271917700Medicaid
FLI17514Medicare UPIN
FLU3071YMedicare ID - Type Unspecified
FLU3071XMedicare PIN