Provider Demographics
NPI:1417980913
Name:KENSHOCK, EDWARD M (OD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:KENSHOCK
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 1:1726 METROMEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3861
Mailing Address - Country:US
Mailing Address - Phone:910-484-2284
Mailing Address - Fax:910-484-1673
Practice Address - Street 1:1629 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3456
Practice Address - Country:US
Practice Address - Phone:910-484-2284
Practice Address - Fax:910-484-1673
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093JUMedicaid
MK0611194OtherDEA
NC89093JUMedicaid
MK0611194OtherDEA