Provider Demographics
NPI:1952304230
Name:HERLIHY, KENNETH W (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:HERLIHY
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 1:2469 STATE ROUTE 19 N
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-9336
Mailing Address - Country:US
Mailing Address - Phone:585-786-2288
Mailing Address - Fax:585-786-3699
Practice Address - Street 1:2469 STATE ROUTE 19 N
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-9336
Practice Address - Country:US
Practice Address - Phone:585-786-2288
Practice Address - Fax:585-786-3699
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT004848174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01676879Medicaid
NY01676879Medicaid
NYE30212Medicare ID - Type Unspecified