Provider Demographics
NPI:1982269437
Name:OCONNOR, KENNETH III (DOM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:OCONNOR
Suffix:III
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19027 RED BIRD LN
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-1815
Mailing Address - Country:US
Mailing Address - Phone:617-584-1816
Mailing Address - Fax:
Practice Address - Street 1:1511 TAMIAMI TRL S STE 202
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5578
Practice Address - Country:US
Practice Address - Phone:941-228-4688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4051171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist