Provider Demographics
NPI:1073516910
Name:FALKNOR, KENNETH RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAY
Last Name:FALKNOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3835
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79923-3835
Mailing Address - Country:US
Mailing Address - Phone:915-544-6700
Mailing Address - Fax:915-544-6707
Practice Address - Street 1:2222 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3602
Practice Address - Country:US
Practice Address - Phone:915-544-6700
Practice Address - Fax:915-544-6707
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2538TG152WC0802X
TX02538TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037029802Medicaid
TX80663QOtherBLUE CROSS BLUE SHIELD
TX037029802Medicaid
TXP00191020Medicare PIN
TXT13220Medicare UPIN
TX4453620001Medicare NSC