Provider Demographics
NPI:1295065944
Name:GOETZ, KENNETH MICHAEL (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:GOETZ
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 RIVER OAKS COURT
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43659-1875
Mailing Address - Country:US
Mailing Address - Phone:419-882-1150
Mailing Address - Fax:
Practice Address - Street 1:5320 RIVER OAKS COURT
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43659-1875
Practice Address - Country:US
Practice Address - Phone:419-882-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161403207R00000X
OH35-0713382083X0100X
NJ25MA057827002083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD - 91861Medicare UPIN