Provider Demographics
NPI:1154415479
Name:GLASS, KENNETH R (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:GLASS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 FLOWER LN
Mailing Address - Street 2:OPTICARE INC.
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2312
Mailing Address - Country:US
Mailing Address - Phone:516-775-7595
Mailing Address - Fax:516-775-7595
Practice Address - Street 1:38 FLOWER LN
Practice Address - Street 2:OPTICARE INC.
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2312
Practice Address - Country:US
Practice Address - Phone:516-775-7595
Practice Address - Fax:516-775-7595
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004288152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC43371Medicare PIN
NY64857GMedicare PIN