Provider Demographics
NPI:1427161173
Name:YAKER, KENNETH M (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:M
Last Name:YAKER
Suffix:
Gender:M
Credentials:MD
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 445
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90294-0445
Mailing Address - Country:US
Mailing Address - Phone:310-408-6357
Mailing Address - Fax:213-365-2924
Practice Address - Street 1:3019 S. FREEWAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:323-868-8099
Practice Address - Fax:815-550-1658
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75747208D00000X
TXP3488208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF98955Medicare UPIN
CAG75747Medicare ID - Type UnspecifiedPROVIDER NUMBER