Provider Demographics
NPI:1578568770
Name:KISH, ROBERT JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:KISH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:748 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4273
Mailing Address - Country:US
Mailing Address - Phone:860-448-3937
Mailing Address - Fax:860-449-0343
Practice Address - Street 1:748 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4273
Practice Address - Country:US
Practice Address - Phone:860-448-3937
Practice Address - Fax:860-449-0343
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT797152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
U42002Medicare UPIN