Provider Demographics
NPI:1366421422
Name:SAPP, KENNETH W (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:SAPP
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 1:325 EAST BLODGETT AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2112
Mailing Address - Country:US
Mailing Address - Phone:847-482-1938
Mailing Address - Fax:
Practice Address - Street 1:3001A SIXTH STREET
Practice Address - Street 2:LABORATORY, NAVAL HEALTH CLINIC GREAT LAKES
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037035207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology