Provider Demographics
NPI:1942290929
Name:HAINSWORTH, KENNETH M (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:HAINSWORTH
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 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:
Practice Address - Street 1:1818 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4803
Practice Address - Country:US
Practice Address - Phone:208-455-2355
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8605207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDJ6576OtherBLUE CROSS
ID180044930OtherRAILROAD MEDICARE
ID000010138765OtherBLUE SHIELD
ID48801OtherBLUE CROSS
ID806365500Medicaid
ID000010138766OtherBLUE SHIELD
ID180044930OtherRAILROAD MEDICARE
ID20002158Medicare PIN
ID000010138765OtherBLUE SHIELD
H66058Medicare UPIN