Healthcare Provider Details

I. General information

NPI: 1568426047
Provider Name (Legal Business Name): KENNETH L. JANSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4443 LYONS RD STE 211
COCONUT CREEK FL
33073-4388
US

IV. Provider business mailing address

4443 LYONS RD STE 211
COCONUT CREEK FL
33073-4388
US

V. Phone/Fax

Practice location:
  • Phone: 954-405-0501
  • Fax: 954-301-8501
Mailing address:
  • Phone: 954-405-0501
  • Fax: 954-301-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-043934
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberME111647
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: