Provider Demographics
NPI:1285717678
Name:BRETTS, KENNETH (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BRETTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 W. 26TH ST.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4036
Mailing Address - Country:US
Mailing Address - Phone:773-277-6589
Mailing Address - Fax:773-277-1841
Practice Address - Street 1:3303 W. 26TH ST.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4036
Practice Address - Country:US
Practice Address - Phone:773-277-6589
Practice Address - Fax:773-277-1841
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-050271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
367830Medicare PIN
C41991Medicare UPIN