Provider Demographics
NPI:1780858860
Name:LIEN, KENNY (MD)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:LIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BOI
Other - Middle Name:KHIEM
Other - Last Name:LIEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:75 N COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-476-2767
Mailing Address - Fax:631-473-0132
Practice Address - Street 1:75 N COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-476-2767
Practice Address - Fax:631-473-0132
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261820-I2085R0202X, 2085R0204X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY261820-1OtherNEW YORK STATE LICENSE