Provider Demographics
NPI:1407899248
Name:KATTA, KENNETH STANLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:STANLEY
Last Name:KATTA
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 1:89 SEELEY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1011
Mailing Address - Country:US
Mailing Address - Phone:917-620-1081
Mailing Address - Fax:
Practice Address - Street 1:844 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3189
Practice Address - Country:US
Practice Address - Phone:718-941-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3825-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02385817Medicaid
NY02385817Medicaid
NYC529BWS431Medicare PIN