Provider Demographics
NPI:1811146483
Name:ANDERSON, KENNETH PAUL (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAUL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:PAUL
Other - Last Name:ANDERSON
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2008
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.121924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine