Provider Demographics
NPI:1023143419
Name:SANDKER, KENNETH J (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:SANDKER
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:PO BOX 377
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-0377
Mailing Address - Country:US
Mailing Address - Phone:419-586-3151
Mailing Address - Fax:419-586-1059
Practice Address - Street 1:1025 GRAND LAKE RD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1309
Practice Address - Country:US
Practice Address - Phone:419-586-3151
Practice Address - Fax:419-586-1059
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000367947OtherANTHEM
OH141478OtherCOLE MANAGED VISION
OH71115OtherDAVIS VISION
OHT47290Medicare UPIN
OH71115OtherDAVIS VISION