Provider Demographics
NPI:1063486967
Name:PUTLAND, KENNETH WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WILLIAM
Last Name:PUTLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10852 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-3741
Practice Address - Country:US
Practice Address - Phone:757-594-3602
Practice Address - Fax:757-594-3605
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE78438Medicare UPIN
VA1063486967Medicaid
VA015154R53Medicare PIN
VA110087986Medicare PIN