Provider Demographics
NPI:1255529673
Name:KURT, KENNETH J (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:KURT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 S GREEN BAY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4410
Mailing Address - Country:US
Mailing Address - Phone:262-631-0474
Mailing Address - Fax:262-631-0476
Practice Address - Street 1:1532 S GREEN BAY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4410
Practice Address - Country:US
Practice Address - Phone:262-631-0474
Practice Address - Fax:262-631-0476
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30038200Medicaid
WIB54385Medicare UPIN