Provider Demographics
NPI:1063413854
Name:KENEFICK, TIMOTHY H (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:H
Last Name:KENEFICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 MORGAN ST.
Mailing Address - Street 2:THE PEDIATRIC CENTER
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5431
Mailing Address - Country:US
Mailing Address - Phone:203-327-1055
Mailing Address - Fax:203-323-6177
Practice Address - Street 1:126 MORGAN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5431
Practice Address - Country:US
Practice Address - Phone:203-327-1055
Practice Address - Fax:203-323-6177
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028872208000000X
NY163113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001288720Medicaid
00764RMedicare UPIN