Provider Demographics
NPI:1609871763
Name:GANLY, KEN E (OD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:E
Last Name:GANLY
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 1:109 HILLSIDE LN
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-2267
Mailing Address - Country:US
Mailing Address - Phone:484-678-7276
Mailing Address - Fax:
Practice Address - Street 1:402 BAYARD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-1862
Practice Address - Country:US
Practice Address - Phone:484-770-8132
Practice Address - Fax:484-770-8136
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-000362152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA460176OtherINDIVIDUAL AETNA ID
PAPA7531OtherEYEMED INSURANCE PROVIDER
GA90560Medicare ID - Type Unspecified
PAU44612Medicare UPIN