Provider Demographics
NPI:1568436095
Name:SMITH, KENNETH C (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:SMITH
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 1:401 E 34TH ST
Mailing Address - Street 2:SOUTH 3B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4914
Mailing Address - Country:US
Mailing Address - Phone:212-679-0766
Mailing Address - Fax:
Practice Address - Street 1:401 E 34TH ST
Practice Address - Street 2:SOUTH 3B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4914
Practice Address - Country:US
Practice Address - Phone:212-679-0766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005868-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02151302Medicaid
NY6599281OtherGHI
NYC367E1OtherEMPIRE BLUE CROSS BLUE SH
NYP2929150OtherOXFORD HEALTH PLAN
NY1561736OtherCIGNA
NY18216POtherHIP
NY3750977OtherAETNA HMO
NY7652507OtherAETNA PPO/EPO
NY6C0858OtherHEALTHNET
NY7652507OtherAETNA PPO/EPO
NY6599281OtherGHI
NY07758GMedicare PIN