Provider Demographics
NPI:1942366125
Name:WAINWRIGHT, KENNETH (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:WAINWRIGHT
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 1:2201 W OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-2625
Mailing Address - Country:US
Mailing Address - Phone:818-845-3783
Mailing Address - Fax:818-845-1065
Practice Address - Street 1:2201 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2625
Practice Address - Country:US
Practice Address - Phone:818-845-3783
Practice Address - Fax:818-845-1065
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA4937152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU28633Medicare UPIN
CAOP4937Medicare ID - Type Unspecified