Provider Demographics
NPI:1164570230
Name:PERKINS, KENNETH LEON (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEON
Last Name:PERKINS
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 1:435 VALLEYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3067
Mailing Address - Country:US
Mailing Address - Phone:423-842-1050
Mailing Address - Fax:423-842-7246
Practice Address - Street 1:5407 HIXSON PIKE
Practice Address - Street 2:SUITE 121
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4559
Practice Address - Country:US
Practice Address - Phone:423-842-1050
Practice Address - Fax:423-842-7246
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0001030152W00000X
GAOPT001085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0068706OtherBLUECROSS BLUESHIEL OF TN
TN702024767OtherCARITEN
TN0068706OtherBLUECROSS BLUESHIEL OF TN
410047982Medicare ID - Type UnspecifiedRAILROAD MEDICARE
TN702024767OtherCARITEN