Provider Demographics
NPI:1194724500
Name:KETTER, IVAN C (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:C
Last Name:KETTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1657
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66601-1657
Mailing Address - Country:US
Mailing Address - Phone:785-295-8108
Mailing Address - Fax:785-231-5991
Practice Address - Street 1:2835 SW MISSION WOODS DR
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-5616
Practice Address - Country:US
Practice Address - Phone:785-271-1818
Practice Address - Fax:785-232-0739
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS422467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100120190BMedicaid
KS100120190BMedicaid