Provider Demographics
NPI:1093140162
Name:KIERSTEIN, KENNETH R (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:KIERSTEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:860-444-0074
Practice Address - Street 1:196 PARKWAY S
Practice Address - Street 2:SUITE 302
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1234
Practice Address - Country:US
Practice Address - Phone:860-447-1488
Practice Address - Fax:860-447-1489
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT98213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTUMedicare UPIN