Provider Demographics
NPI:1013043389
Name:DR. KENNETH O'DANIEL & ASSOC., PC
Entity Type:Organization
Organization Name:DR. KENNETH O'DANIEL & ASSOC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:O'DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:480-945-9971
Mailing Address - Street 1:7014 E CAMELBACK RD
Mailing Address - Street 2:SUITE 2140
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-1227
Mailing Address - Country:US
Mailing Address - Phone:480-945-9971
Mailing Address - Fax:480-990-1100
Practice Address - Street 1:7014 E CAMELBACK RD
Practice Address - Street 2:SUITE 2140
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-1227
Practice Address - Country:US
Practice Address - Phone:480-945-9971
Practice Address - Fax:480-990-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ 0694152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT80065Medicare UPIN
AZ72658Medicare ID - Type Unspecified