Provider Demographics
NPI:1134191471
Name:KETVERTIS, KARI MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:KARI
Middle Name:MICHELLE
Last Name:KETVERTIS
Suffix:
Gender:F
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:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:808 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:OH
Practice Address - Zip Code:44839
Practice Address - Country:US
Practice Address - Phone:419-433-6117
Practice Address - Fax:419-433-7226
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-086419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00639734OtherRAILROAD MEDICARE
OH2599700Medicaid
OH2599700Medicaid
H74997Medicare UPIN