Provider Demographics
NPI:1760510630
Name:STEIN, KENNETH ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALAN
Last Name:STEIN
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 1:3545 MACNICHOL TRL
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1736
Mailing Address - Country:US
Mailing Address - Phone:248-538-1501
Mailing Address - Fax:740-539-1501
Practice Address - Street 1:3545 MACNICHOL TRL
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-1736
Practice Address - Country:US
Practice Address - Phone:248-756-0078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003157152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1760510630Medicaid
MI1760510630Medicaid