Provider Demographics
NPI:1407162043
Name:STATSICK, KENNETH RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RICHARD
Last Name:STATSICK
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 1:2803 CASHWELL DR
Mailing Address - Street 2:STE A
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4301
Mailing Address - Country:US
Mailing Address - Phone:919-778-2015
Mailing Address - Fax:919-778-4808
Practice Address - Street 1:2803 CASHWELL DR
Practice Address - Street 2:STE A
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4301
Practice Address - Country:US
Practice Address - Phone:919-778-2015
Practice Address - Fax:919-778-4808
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4549152W00000X
NC2303152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC374OtherMEDICARE PTAN
NC12143984OtherCAQH
NC5922830OtherMEDICAID PIN
NC5922830OtherMEDICAID PTAN