Provider Demographics
NPI:1154387918
Name:PEARSEN, KENNETH D (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:PEARSEN
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 1:111 N MAPLEMERE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3178
Mailing Address - Country:US
Mailing Address - Phone:716-836-4646
Mailing Address - Fax:716-836-4696
Practice Address - Street 1:111 N MAPLEMERE RD STE 120
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3178
Practice Address - Country:US
Practice Address - Phone:716-836-4646
Practice Address - Fax:716-836-4696
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1818342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00025335602OtherUNIVERA
P010181834OtherBLUE CHOICE
NY01230148Medicaid
101326FFOtherPREFERRED CARE
0142865OtherGHI
P020181834OtherBLUE SHIELD ROCHESTER
000911558011OtherBLUE SHIELD WNY
P00005729OtherRR MEDICARE
00025335605OtherUNIVERA
04026003061OtherFIDELIS
1693149OtherINDEPENDENT HEALTH
4195929OtherGHI
000911558015OtherBLUE SHIELD WNY
NY1818343BOtherWORKERS COMPENSATION
04026003061OtherFIDELIS
NY01230148Medicaid
DD4876Medicare PIN
DD6590Medicare PIN