Basic Information
| Provider Information | |||||||||
| NPI: | 1770664138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABBOTT | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2968 | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465152968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963200 | ||||||||
| FaxNumber: | 5742963544 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 W LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742943030 | ||||||||
| FaxNumber: | 5742943544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 0102595A | IN | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 100112470 | 05 | IN | MEDICAID | 180041763 | 01 | IN | RAILROAD MEDICARE | OTHER |