Provider Demographics
NPI:1104819465
Name:FORD, JOHN KENNETH (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNETH
Last Name:FORD
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:PO BOX 111556
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98411-1556
Mailing Address - Country:US
Mailing Address - Phone:253-686-8840
Mailing Address - Fax:253-572-6632
Practice Address - Street 1:3407 E M ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-3931
Practice Address - Country:US
Practice Address - Phone:206-275-9705
Practice Address - Fax:425-484-6425
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000753173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1118249Medicaid
WA0177187OtherL&I
WAU96196Medicare UPIN
WA0177187OtherL&I