Provider Demographics
NPI:1659543031
Name:KENNETH L. BURKE, O.D.
Entity Type:Organization
Organization Name:KENNETH L. BURKE, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-263-3391
Mailing Address - Street 1:PO BOX 384
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-0384
Mailing Address - Country:US
Mailing Address - Phone:203-263-3391
Mailing Address - Fax:
Practice Address - Street 1:175 MAIN ST S
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3448
Practice Address - Country:US
Practice Address - Phone:203-263-3391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0552550001Medicare NSC