Provider Demographics
NPI:1952366601
Name:DODGE, KENNETH R (RPAC)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:DODGE
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2340
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11969-2340
Mailing Address - Country:US
Mailing Address - Phone:631-283-2100
Mailing Address - Fax:631-283-5731
Practice Address - Street 1:200 PANTIAGO PLACE
Practice Address - Street 2:STE J
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937
Practice Address - Country:US
Practice Address - Phone:631-324-7700
Practice Address - Fax:631-324-7701
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2008-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0001001363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01271329Medicaid