Provider Demographics
NPI:1093725236
Name:GARROD, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:GARROD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 CLINT MOORE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2658
Mailing Address - Country:US
Mailing Address - Phone:561-241-4758
Mailing Address - Fax:561-998-4246
Practice Address - Street 1:1905 CLINT MOORE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2658
Practice Address - Country:US
Practice Address - Phone:561-241-4758
Practice Address - Fax:561-998-4246
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB98821Medicare UPIN
FL3915700001Medicare NSC
FL200040588Medicare PIN
FL61348TMedicare PIN