Provider Demographics
NPI:1881608263
Name:BURKE, KENNETH L (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:BURKE
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:PO BOX 384
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-0384
Mailing Address - Country:US
Mailing Address - Phone:203-263-3391
Mailing Address - Fax:203-263-3390
Practice Address - Street 1:175 MAIN ST S
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3405
Practice Address - Country:US
Practice Address - Phone:203-263-3391
Practice Address - Fax:203-263-3390
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000817152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT83587OtherAETNA
CT090000817CT01OtherANTHEM
CT3582OtherDAVIS VISION
CTP382850OtherOXFORD
CT009287OtherBLOCK
CT658049OtherCONNECTICARE
CT0V0992OtherHEALTHNET
CT0V0992OtherHEALTHNET
CT009287OtherBLOCK