Provider Demographics
NPI:1891977377
Name:GLASGOW, KENNETH J (OPTICIAN AAS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:GLASGOW
Suffix:
Gender:M
Credentials:OPTICIAN AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1105
Mailing Address - Country:US
Mailing Address - Phone:716-883-2020
Mailing Address - Fax:716-883-2020
Practice Address - Street 1:41 NORTH STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1105
Practice Address - Country:US
Practice Address - Phone:716-883-2020
Practice Address - Fax:716-883-2020
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC003597156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00594803Medicaid
NY4500000001Medicare UPIN