Provider Demographics
NPI:1316150949
Name:SEITER, KENNETH PAUL JR (DPM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PAUL
Last Name:SEITER
Suffix:JR
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:PO BOX 402319
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2319
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1500 DODSON AVE
Practice Address - Street 2:STE 290
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5182
Practice Address - Country:US
Practice Address - Phone:479-573-7905
Practice Address - Fax:479-573-7906
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99026414213E00000X
AR240213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR171066717Medicaid
OK200202360AMedicaid
INV12425Medicare UPIN
OK200202360AMedicaid
IN227180IMedicare PIN