Provider Demographics
NPI:1124179486
Name:KETTWICH, DONALD LEE (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:LEE
Last Name:KETTWICH
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 1:711 ENCINO PL NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2619
Mailing Address - Country:US
Mailing Address - Phone:505-245-5737
Mailing Address - Fax:505-245-5739
Practice Address - Street 1:711 ENCINO PL NE
Practice Address - Street 2:SUITE E
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2619
Practice Address - Country:US
Practice Address - Phone:505-245-5737
Practice Address - Fax:505-245-5739
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM76-208208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00015941Medicaid
NM85-0284119OtherJOHN ALDEN
NM00NM019E05OtherBLUE CROSS-BLUE SHIELD-NM
NM85-0284119OtherTRICARE FOR LIFE
NM85-0284119OtherIBEW-NECA
NM85-0284119OtherGEHA
NM85-0284119OtherAARP
NM85-0284119OtherE.B.C.
NM201005185OtherPRESBYTERIAN HEALTH PLAN
NM85-0284119OtherLOVELACE HEALTH PLAN
NM85-0284119OtherPRINCIPAL LIFE INS.
NM85-0284119OtherUNITED HEALTHCARE
NM85-0284119OtherCIGNA
NM85-0284119OtherUPREHS
NM85-0284119OtherUNITED AMERICAN
NM85-0284119OtherN.M. PIPE TRADES
NM85-0284119OtherAETNA
NM85-0284119OtherJOHN ALDEN
NM826341273Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NM335731901Medicare PIN