Provider Demographics
NPI:1194909853
Name:NUZZO, KENNETH FRED (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:FRED
Last Name:NUZZO
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 1:31 WATER ST
Mailing Address - Street 2:
Mailing Address - City:HALLOWELL
Mailing Address - State:ME
Mailing Address - Zip Code:04347-1440
Mailing Address - Country:US
Mailing Address - Phone:207-622-3015
Mailing Address - Fax:207-622-1299
Practice Address - Street 1:31 WATER ST
Practice Address - Street 2:
Practice Address - City:HALLOWELL
Practice Address - State:ME
Practice Address - Zip Code:04347-1440
Practice Address - Country:US
Practice Address - Phone:207-622-3015
Practice Address - Fax:207-622-1299
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME115450099Medicaid
MEGX7059Medicare PIN
ME115450099Medicaid
ME0370640002Medicare NSC
MEGX7055Medicare PIN
ME0370640001Medicare NSC