Provider Demographics
NPI:1285709626
Name:PHILLIPS, KENNETH A (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:PHILLIPS
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:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:WAYMART
Mailing Address - State:PA
Mailing Address - Zip Code:18472-0310
Mailing Address - Country:US
Mailing Address - Phone:570-488-6710
Mailing Address - Fax:
Practice Address - Street 1:314 HONESDALE ROAD
Practice Address - Street 2:
Practice Address - City:WAYMART
Practice Address - State:PA
Practice Address - Zip Code:18472-0310
Practice Address - Country:US
Practice Address - Phone:570-488-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA075457OtherFIRST PRIORITY
PA390770OtherNVA
PA18765OtherGEISINGER
PAOEG000530OtherVBA
PA0829700OtherAETNA
PAPH289044OtherCLARITY VISION
PA0829700OtherAETNA
PA075457OtherFIRST PRIORITY