Provider Demographics
NPI:1750614699
Name:FERJENTSIK, KELLY MCGLYNN (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MCGLYNN
Last Name:FERJENTSIK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:B
Other - Last Name:MCGLYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:14 CHURCH HILL ROAD
Mailing Address - Street 2:SUITE C 10
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470
Mailing Address - Country:US
Mailing Address - Phone:203-426-2727
Mailing Address - Fax:203-426-5113
Practice Address - Street 1:14 CHURCH HILL ROAD
Practice Address - Street 2:SUITE C 10
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470
Practice Address - Country:US
Practice Address - Phone:203-426-2727
Practice Address - Fax:203-426-5113
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4764152W00000X
CT002854152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist