Provider Demographics
NPI:1568414993
Name:MARICI, KENNETH F (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:F
Last Name:MARICI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 OLD PARK LANE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-2561
Mailing Address - Country:US
Mailing Address - Phone:860-354-5511
Mailing Address - Fax:860-350-3122
Practice Address - Street 1:2 OLD PARK LANE RD STE 1
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2561
Practice Address - Country:US
Practice Address - Phone:860-354-5511
Practice Address - Fax:860-350-3122
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001365205Medicaid
G67415Medicare UPIN
CT001365205Medicaid