Provider Demographics
NPI:1891863528
Name:MACOUL, KENNETH L (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:MACOUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840
Mailing Address - Country:US
Mailing Address - Phone:978-685-5366
Mailing Address - Fax:978-685-4867
Practice Address - Street 1:280 HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840
Practice Address - Country:US
Practice Address - Phone:978-685-5366
Practice Address - Fax:978-685-4867
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30171207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D13190OtherBCBS OF MA
D13190OtherBCBS OF MA
D13190Medicare ID - Type Unspecified