Provider Demographics
NPI:1861582231
Name:WAITHE, KENRICK
Entity type:Individual
Prefix:
First Name:KENRICK
Middle Name:
Last Name:WAITHE
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 1:21 ELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-3403
Mailing Address - Country:US
Mailing Address - Phone:718-901-6471
Mailing Address - Fax:718-716-4780
Practice Address - Street 1:1591 FULTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-8234
Practice Address - Country:US
Practice Address - Phone:718-901-6470
Practice Address - Fax:718-716-4780
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH57673Medicare UPIN