Individual
KEITH ENNIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1907 W SYCAMORE ST, KOKOMO, IN 46901-5148
(765) 456-5433
Mailing address
1907 W SYCAMORE ST, KOKOMO, IN 46901-5148
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01040472A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200014450E
—
IN
Enumeration date
10/24/2006
Last updated
06/20/2022
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