Provider Demographics
NPI:1932101532
Name:HAWN, KENNETH D (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:HAWN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:509 HAMACHER ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-939-2273
Mailing Address - Fax:618-939-0245
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-2273
Practice Address - Fax:618-939-0245
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4451208000000X
MO2003018920208000000X
IL036135043208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157028001Medicaid