Provider Demographics
NPI:1144396227
Name:KENZIE, PAUL WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WALTER
Last Name:KENZIE
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 1:108 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1236
Mailing Address - Country:US
Mailing Address - Phone:734-453-8450
Mailing Address - Fax:734-453-6347
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1236
Practice Address - Country:US
Practice Address - Phone:734-453-8450
Practice Address - Fax:734-453-6347
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002510152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0222940001Medicare ID - Type Unspecified
MIT33799Medicare UPIN