Provider Demographics
NPI:1427053255
Name:BLUMENTHAL, KENNETH WAYNE (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:BLUMENTHAL
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 1:2802 LEONARD DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-7136
Mailing Address - Country:US
Mailing Address - Phone:219-531-5855
Mailing Address - Fax:219-531-1617
Practice Address - Street 1:2802 LEONARD DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-7136
Practice Address - Country:US
Practice Address - Phone:219-531-5855
Practice Address - Fax:219-531-1617
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN080152596OtherRAILROAD MEDICARE
IN100352990Medicaid
IN000000093874OtherAMTHEM BC/BS
IN4157960001Medicare NSC
IN149070AMedicare ID - Type Unspecified
IN100352990Medicaid