Provider Demographics
NPI:1932112547
Name:KINGSLY, KENNETH ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALAN
Last Name:KINGSLY
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 1:425 POST ROAD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824
Mailing Address - Country:US
Mailing Address - Phone:203-254-1576
Mailing Address - Fax:203-254-1809
Practice Address - Street 1:425 POST ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824
Practice Address - Country:US
Practice Address - Phone:203-254-1576
Practice Address - Fax:203-254-1809
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039816208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001398165Medicaid
H46280Medicare UPIN
340000342Medicare ID - Type Unspecified