Provider Demographics
NPI:1912083130
Name:CHAFFEE, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:CHAFFEE
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 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1316 E. 7TH STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2539
Practice Address - Country:US
Practice Address - Phone:260-333-7704
Practice Address - Fax:260-333-7705
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028114A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3134012Medicaid
IN100152470Medicaid
IN259990008Medicare PIN
IN192110Medicare ID - Type Unspecified
IN000000683952OtherANTHEM
IN000000092587OtherANTHEM
OH3134012Medicaid