Provider Demographics
NPI:1184620908
Name:TABOR, KENDALL P (DPM, FACFS)
Entity type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:P
Last Name:TABOR
Suffix:
Gender:M
Credentials:DPM, FACFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 HOWARD ST
Mailing Address - Street 2:STE 215
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1917
Mailing Address - Country:US
Mailing Address - Phone:269-385-1000
Mailing Address - Fax:269-385-5120
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:STE 215
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-7709
Practice Address - Fax:906-225-7707
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001089213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1053597914OtherNPPES
MI2126020Medicaid
MIT34101Medicare UPIN
MI0753140001Medicare NSC
MI2126020Medicaid