Provider Demographics
NPI:1578542221
Name:TENNANT, KENNETH ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:TENNANT
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 1:223 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-1351
Mailing Address - Country:US
Mailing Address - Phone:706-343-1876
Mailing Address - Fax:706-343-1877
Practice Address - Street 1:223 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-1351
Practice Address - Country:US
Practice Address - Phone:706-343-1876
Practice Address - Fax:706-343-1877
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA374592414BMedicaid
41ZCFSLMedicare PIN
GAU95485Medicare UPIN
GA5340070001Medicare NSC