Provider Demographics
NPI:1497818462
Name:SPECTOR, KENNETH S (MD PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:SPECTOR
Suffix:
Gender:M
Credentials:MD PHD
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 354
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418
Mailing Address - Country:US
Mailing Address - Phone:203-732-7455
Mailing Address - Fax:203-735-5507
Practice Address - Street 1:130 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418
Practice Address - Country:US
Practice Address - Phone:203-732-7455
Practice Address - Fax:203-735-5507
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040935207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT06001511Medicare ID - Type Unspecified
H47376Medicare UPIN