Provider Demographics
NPI:1245334358
Name:AMPEL, KENNETH ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:AMPEL
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 1:1014 BLACK OAK DR.
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-779-3859
Mailing Address - Fax:
Practice Address - Street 1:1698 E MCANDREWS RD
Practice Address - Street 2:#400
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5589
Practice Address - Country:US
Practice Address - Phone:541-732-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD10107OtherOR MEDICAL LICENSE