Provider Demographics
NPI:1417950353
Name:HUBBARD, KENNETH N JR (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:N
Last Name:HUBBARD
Suffix:JR
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:PO BOX 2417
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-2417
Mailing Address - Country:US
Mailing Address - Phone:870-741-2787
Mailing Address - Fax:870-741-6714
Practice Address - Street 1:519 N WILLOW ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3518
Practice Address - Country:US
Practice Address - Phone:870-741-2787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2093152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR48784OtherBLCR AND OTHER ID NUMBER
AR5C405OtherCLINIC
AR0253600002Medicare NSC
AR48784C405Medicare PIN
AR48784OtherBLCR AND OTHER ID NUMBER