Provider Demographics
NPI:1518042092
Name:EGAN, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:EGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:107 NEWTOWN RD
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4146
Mailing Address - Country:US
Mailing Address - Phone:203-790-8930
Mailing Address - Fax:203-790-8930
Practice Address - Street 1:107 NEWTOWN RD
Practice Address - Street 2:SUITE 2C
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4146
Practice Address - Country:US
Practice Address - Phone:203-790-8930
Practice Address - Fax:203-790-8930
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT029527207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070000178Medicare ID - Type Unspecified
A62097Medicare UPIN