Provider Demographics
NPI:1093797052
Name:DETRING, KENNETH CHARLES (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHARLES
Last Name:DETRING
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 510
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-0510
Mailing Address - Country:US
Mailing Address - Phone:573-243-2020
Mailing Address - Fax:573-243-6684
Practice Address - Street 1:1014 E JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2436
Practice Address - Country:US
Practice Address - Phone:573-243-2020
Practice Address - Fax:573-243-6684
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0348270001Medicare NSC
MOT42576Medicare UPIN