MEDICARE: DR. DAVID LAWRENCE KETTL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	D31677	MD

General Provider Information

NPI Number	:	1730264706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID LAWRENCE KETTL MD

Provider Business Mailing Address
First Line	:	12017 CITRUS GROVE RD
Second Line	:
City	:	NORTH POTOMAC
State	:	MD
Zip	:	20878-4913
Country	:	US
Telephone Number	:	301-796-2105
Fax Number	:	301-796-9895

Provider Business Practice Location Address
First Line	:	12017 CITRUS GROVE RD
Second Line	:
City	:	NORTH POTOMAC
State	:	MD
Zip	:	20878-4913
Country	:	US
Telephone Number	:	301-796-2105
Fax Number	:	301-796-9895

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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