Provider Demographics
NPI:1154374544
Name:GARCIA, KENNETH J (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:GARCIA
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 1:1575 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9367
Mailing Address - Country:US
Mailing Address - Phone:315-779-5060
Mailing Address - Fax:315-779-5028
Practice Address - Street 1:6 GLEN COVE DR
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4272
Practice Address - Country:US
Practice Address - Phone:207-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1744642084P0800X
MEMD276452084P0800X
CT506632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354316Medicaid
NY00354316Medicaid