Provider Demographics
NPI:1831283662
Name:SCHWARTZ, KENNETH ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:SCHWARTZ
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 1:704 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-2238
Mailing Address - Country:US
Mailing Address - Phone:718-376-5288
Mailing Address - Fax:718-382-0263
Practice Address - Street 1:704 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2238
Practice Address - Country:US
Practice Address - Phone:718-376-5288
Practice Address - Fax:718-382-0263
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0029671152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY32002967-1Medicaid
NYT48926Medicare UPIN
NY32002967-1Medicaid