Provider Demographics
NPI:1699702373
Name:ICZKOWSKI, KENNETH ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALAN
Last Name:ICZKOWSKI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6966
Mailing Address - Fax:414-805-6980
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6966
Practice Address - Fax:414-805-6980
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO45517207ZP0101X
OH097071207ZP0101X
WV24404207ZP0101X
PA065446-L207ZP0101X
WI60981207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93707240Medicaid
WI1699702373Medicaid