Provider Demographics
NPI:1972617355
Name:SUPPES, KENNETH JOHN (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:SUPPES
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 1:1885 N CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-5565
Mailing Address - Country:US
Mailing Address - Phone:989-792-6627
Mailing Address - Fax:
Practice Address - Street 1:1885 N CENTER RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-5565
Practice Address - Country:US
Practice Address - Phone:989-792-6627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4742508Medicaid
MIT33559Medicare UPIN