Provider Demographics
NPI:1568490399
Name:HARDY, KENNETH WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:HARDY
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 1:19126 MAGNOLIA ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-2235
Mailing Address - Country:US
Mailing Address - Phone:714-962-6601
Mailing Address - Fax:714-965-0943
Practice Address - Street 1:19126 MAGNOLIA ST
Practice Address - Street 2:SUITE 105
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-2235
Practice Address - Country:US
Practice Address - Phone:714-962-6601
Practice Address - Fax:714-965-0943
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8242T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADD001ZMedicare PIN