Healthcare Provider Details

I. General information

NPI: 1093801730
Provider Name (Legal Business Name): KENNETH C. DEEM M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4265
US

IV. Provider business mailing address

1237 DELAWARE AVE
BUFFALO NY
14209-1435
US

V. Phone/Fax

Practice location:
  • Phone: 253-596-3300
  • Fax:
Mailing address:
  • Phone: 716-362-9585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberRESIDENT IN TRAINING
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: