Provider Demographics
NPI:1093756371
Name:STACK, KENNETH L (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:STACK
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 1:24 ROSEMONT ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-2405
Mailing Address - Country:US
Mailing Address - Phone:518-438-6669
Mailing Address - Fax:518-489-4372
Practice Address - Street 1:24 ROSEMONT ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-2405
Practice Address - Country:US
Practice Address - Phone:518-438-6669
Practice Address - Fax:518-489-4372
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004607-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY931291Medicaid
NY931291Medicaid
26670Medicare UPIN