Provider Demographics
NPI:1871505461
Name:INCHALIK, KENNETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:INCHALIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4 FARM SPRINGS RD
Mailing Address - Street 2:PROHEALTH PHYSICIANS
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2573
Mailing Address - Country:US
Mailing Address - Phone:860-284-5200
Mailing Address - Fax:860-284-5333
Practice Address - Street 1:2130 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2283
Practice Address - Country:US
Practice Address - Phone:860-659-4414
Practice Address - Fax:860-659-3320
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT026797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG21659Medicare UPIN