Healthcare Provider Details

I. General information

NPI: 1427000967
Provider Name (Legal Business Name): KENNETH R KIDD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W MAIN ST
WHITEWATER WI
53190-1503
US

IV. Provider business mailing address

1305 W MAIN ST
WHITEWATER WI
53190-1503
US

V. Phone/Fax

Practice location:
  • Phone: 262-473-4548
  • Fax: 262-472-7691
Mailing address:
  • Phone: 262-473-4548
  • Fax: 262-472-7691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23985-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: