Provider Demographics
NPI:1134162019
Name:KATZ, KENNETH HENRY (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:HENRY
Last Name:KATZ
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-683-5278
Mailing Address - Fax:920-686-9674
Practice Address - Street 1:1515 RANDOLPH CT
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-8345
Practice Address - Country:US
Practice Address - Phone:920-683-5278
Practice Address - Fax:920-686-9674
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39233020207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39233-020OtherSTATE LICENSE
WI32579200Medicaid
WIO70016217OtherRAILROAD MEDICARE
WIBK6338746OtherDEA
WIBK6338746OtherDEA
WIO70016217OtherRAILROAD MEDICARE
WI000238200Medicare ID - Type Unspecified