Provider Demographics
NPI:1225003965
Name:GIFT, KENNETH R (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:GIFT
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 1:886 US HIGHWAY 522
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-9712
Mailing Address - Country:US
Mailing Address - Phone:570-374-0154
Mailing Address - Fax:570-374-0155
Practice Address - Street 1:886 US HIGHWAY 522
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-9712
Practice Address - Country:US
Practice Address - Phone:570-374-0154
Practice Address - Fax:570-374-0155
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAG000099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT28139Medicare UPIN
PWGI69891Medicare ID - Type Unspecified