Provider Demographics
NPI:1386008860
Name:KESTEN, ALAN
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:KESTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-8823
Mailing Address - Country:US
Mailing Address - Phone:845-794-1120
Mailing Address - Fax:845-791-4318
Practice Address - Street 1:300 E BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-8823
Practice Address - Country:US
Practice Address - Phone:845-794-1120
Practice Address - Fax:845-791-4318
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY788427476172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02211934Medicaid