Provider Demographics
NPI:1619059235
Name:MERCHANT, KENNETH JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:MERCHANT
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 1:3334 E 32ND PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-4415
Mailing Address - Country:US
Mailing Address - Phone:918-622-6244
Mailing Address - Fax:918-622-9126
Practice Address - Street 1:3334 E 32ND PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-4415
Practice Address - Country:US
Practice Address - Phone:918-622-6244
Practice Address - Fax:918-622-9126
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1073510001Medicare NSC
OKU38116Medicare UPIN
OKOKA102794Medicare PIN