Provider Demographics
NPI:1770519217
Name:MAYEDA, KENNETH EUGENE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:EUGENE
Last Name:MAYEDA
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 1:1145 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4201
Mailing Address - Country:US
Mailing Address - Phone:206-329-1760
Mailing Address - Fax:
Practice Address - Street 1:2902 BEACON AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-5816
Practice Address - Country:US
Practice Address - Phone:206-322-1211
Practice Address - Fax:206-322-0451
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1202407Medicaid
WAA05112Medicare UPIN
WA8864423Medicare PIN