Provider Demographics
NPI:1184605990
Name:ALLEN, KERRY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:MICHAEL
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:278 BENEDICT AVE
Mailing Address - Street 2:STE. 300 MEDICAL PARK III
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-2399
Mailing Address - Country:US
Mailing Address - Phone:419-668-3295
Mailing Address - Fax:419-668-8861
Practice Address - Street 1:278 BENEDICT AVE
Practice Address - Street 2:STE. 300 MEDICAL PARK III
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2399
Practice Address - Country:US
Practice Address - Phone:419-668-3295
Practice Address - Fax:419-668-8861
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051610-A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0608864Medicaid
OH0608864Medicaid
OH0137650001Medicare NSC
OHAL0616982Medicare ID - Type Unspecified