Provider Demographics
NPI:1114067196
Name:KINGDON, KENNETH MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:KINGDON
Suffix:
Gender:
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:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0577
Mailing Address - Country:US
Mailing Address - Phone:509-689-2517
Mailing Address - Fax:509-689-2086
Practice Address - Street 1:PO BOX 577
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812-0577
Practice Address - Country:US
Practice Address - Phone:509-689-2517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61498906207P00000X
TXP4471207P00000X, 208600000X, 2086S0127X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036126885Medicaid
IL214881172Medicare PIN
IL036126885Medicaid