Provider Demographics
NPI:1841546959
Name:WALLER, KENNETH RUSSELL III (DVM, MS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RUSSELL
Last Name:WALLER
Suffix:III
Gender:M
Credentials:DVM, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 LINDEN DR
Mailing Address - Street 2:ROOM 2058
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53706-1100
Mailing Address - Country:US
Mailing Address - Phone:608-263-7656
Mailing Address - Fax:
Practice Address - Street 1:2015 LINDEN DR
Practice Address - Street 2:ROOM 2058
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53706-1100
Practice Address - Country:US
Practice Address - Phone:608-263-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6054174M00000X
IA7379174M00000X
IL090010797174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian