Provider Demographics
NPI:1992706287
Name:COOMBS, KENNETH EUGENE (DPM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:EUGENE
Last Name:COOMBS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 TERRY RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5103
Mailing Address - Country:US
Mailing Address - Phone:631-724-8285
Mailing Address - Fax:631-724-1598
Practice Address - Street 1:154 TERRY RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5103
Practice Address - Country:US
Practice Address - Phone:631-724-8285
Practice Address - Fax:631-724-1598
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO 37201-1213E00000X
WI518-025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011725369Medicaid
NY011725369Medicaid
NYA400056597Medicare PIN