Basic Information
| Provider Information | |||||||||
| NPI: | 1942290929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAINSWORTH | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E HAWAII AVE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1818 S 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836054803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084552355 | ||||||||
| FaxNumber: | 2084633044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | M8605 | ID | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | J6576 | 01 | ID | BLUE CROSS | OTHER | 180044930 | 01 | ID | RAILROAD MEDICARE | OTHER | 000010138765 | 01 | ID | BLUE SHIELD | OTHER | 48801 | 01 | ID | BLUE CROSS | OTHER | 806365500 | 05 | ID | MEDICAID | 000010138766 | 01 | ID | BLUE SHIELD | OTHER |