Provider Demographics
NPI:1740219112
Name:HOPPER, KENNETH DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DAVID
Last Name:HOPPER
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 1:1675 E MAIN ST
Mailing Address - Street 2:BOX 328
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-5818
Mailing Address - Country:US
Mailing Address - Phone:330-677-3632
Mailing Address - Fax:330-677-8770
Practice Address - Street 1:1930 STATE ROUTE 59
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4112
Practice Address - Country:US
Practice Address - Phone:330-677-3632
Practice Address - Fax:330-677-8770
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040093E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE12899Medicare UPIN