Provider Demographics
NPI:1538179361
Name:KWIATKOWSKI, KENNETH MICHAEL
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:KWIATKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 N MILL ST STE 100
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-6305
Mailing Address - Country:US
Mailing Address - Phone:630-355-6996
Mailing Address - Fax:630-355-0026
Practice Address - Street 1:1250 N MILL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-6304
Practice Address - Country:US
Practice Address - Phone:630-355-6996
Practice Address - Fax:630-355-0026
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070989208000000X
MI5101009035208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070989Medicaid
IL2223081OtherBLUE CROSS
IL2223081OtherBLUE CROSS
AK3276931OtherDEA
IL036070989Medicaid