Provider Demographics
NPI:1780071811
Name:MUELLER, KENNETH JEROME III (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JEROME
Last Name:MUELLER
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 W CARLETON RD STE B
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9458
Mailing Address - Country:US
Mailing Address - Phone:517-610-5469
Mailing Address - Fax:517-586-0228
Practice Address - Street 1:3240 W CARLETON RD STE B
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9458
Practice Address - Country:US
Practice Address - Phone:517-610-5469
Practice Address - Fax:517-586-0228
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2021-10-13
Deactivation Date:2020-08-12
Deactivation Code:
Reactivation Date:2020-08-25
Provider Licenses
StateLicense IDTaxonomies
MI5101024611207RS0010X, 204C00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program