Provider Demographics
NPI:1528061447
Name:GAMMON, KENNETH L (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:GAMMON
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 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3314
Mailing Address - Fax:574-296-3351
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3314
Practice Address - Fax:574-296-3351
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029946A207RP1001X, 208M00000X, 207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112420AMedicaid
INB28626Medicare UPIN
IN100112420AMedicaid