Provider Demographics
NPI:1740336866
Name:WEINER, KENNETH MARC (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARC
Last Name:WEINER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:140 MACOMB
Mailing Address - Street 2:
Mailing Address - City:MT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-464-1472
Practice Address - Street 1:4408 MILESTRIP RD
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219
Practice Address - Country:US
Practice Address - Phone:716-821-9199
Practice Address - Fax:716-821-9456
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0038021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist