Provider Demographics
NPI:1407954142
Name:KENYON, JEFFREY STEVEN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STEVEN
Last Name:KENYON
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 1:385 MENDON ROAD
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895
Mailing Address - Country:US
Mailing Address - Phone:508-994-1400
Mailing Address - Fax:508-910-2212
Practice Address - Street 1:51 STATE RD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-3319
Practice Address - Country:US
Practice Address - Phone:508-994-1400
Practice Address - Fax:508-910-2212
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4577152W00000X
RIODTG00533152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0709565Medicaid
MAW16490OtherB/C B/S OF MASS
MAW16490OtherB/C B/S OF MASS