Provider Demographics
NPI:1184673576
Name:BOYLE, KENNETH ANDREW SR (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ANDREW
Last Name:BOYLE
Suffix:SR
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 1:7875 JOHNNY CAKE RIDGE RD
Mailing Address - Street 2:GREAT LAKES MALL
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5529
Mailing Address - Country:US
Mailing Address - Phone:440-255-2176
Mailing Address - Fax:440-255-1094
Practice Address - Street 1:7875 JOHNNY CAKE RIDGE RD
Practice Address - Street 2:GREAT LAKES MALL
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5529
Practice Address - Country:US
Practice Address - Phone:440-255-2176
Practice Address - Fax:440-255-1094
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0002124Medicaid
OHBO0865151Medicare ID - Type Unspecified
OH0002124Medicaid