Provider Demographics
NPI:1215911870
Name:DANIS, KENNETH M (DPM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:DANIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HISTORY DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3969
Mailing Address - Country:US
Mailing Address - Phone:770-832-3546
Mailing Address - Fax:770-832-3518
Practice Address - Street 1:125 HISTORY DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3969
Practice Address - Country:US
Practice Address - Phone:770-832-3546
Practice Address - Fax:770-832-3518
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000758213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000672306AMedicaid
GAU59194Medicare UPIN
48SCBPVMedicare ID - Type Unspecified