Healthcare Provider Details

I. General information

NPI: 1194724500
Provider Name (Legal Business Name): IVAN C KETTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 SW MISSION WOODS DR
TOPEKA KS
66614-5616
US

IV. Provider business mailing address

PO BOX 1657
TOPEKA KS
66601-1657
US

V. Phone/Fax

Practice location:
  • Phone: 785-271-1818
  • Fax: 785-232-0739
Mailing address:
  • Phone: 785-295-8108
  • Fax: 785-231-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number422467
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: