Individual
DR. KENNETH LANCE KNICKERBOCKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
19900 STATE ROUTE 739, MARYSVILLE, OH 43040-9256
(937) 642-0298
(937) 645-8329
Mailing address
19900 STATE ROUTE 739, MARYSVILLE, OH 43040-9256
(937) 642-0298
(937) 645-8329
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
34 . 008177
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0102036816
STATE LICENSE
VA
01
—
3203
STATE LICENSE
OK
01
—
34 . 008177
STATE LICENSE
OH
Enumeration date
05/23/2007
Last updated
12/16/2009
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