Provider Demographics
NPI:1386255917
Name:MERRITT, KENNETH
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:MERRITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10040 WHITTLE CT
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-4233
Mailing Address - Country:US
Mailing Address - Phone:301-356-2832
Mailing Address - Fax:
Practice Address - Street 1:10040 WHITTLE CT
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-4233
Practice Address - Country:US
Practice Address - Phone:301-356-2832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM630465237881172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver