Provider Demographics
NPI:1376674119
Name:EHRENSALL, KENNETH (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:EHRENSALL
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 1:500 E 77TH ST
Mailing Address - Street 2:APT 1222
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10162-0025
Mailing Address - Country:US
Mailing Address - Phone:917-447-4558
Mailing Address - Fax:718-320-7053
Practice Address - Street 1:2124 BARTOW AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4615
Practice Address - Country:US
Practice Address - Phone:718-379-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist