Provider Demographics
NPI:1174595847
Name:BACKMAN, KENNETH SCOTT (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:SCOTT
Last Name:BACKMAN
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 1:55 WALLS DR
Mailing Address - Street 2:STE. 405
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5163
Mailing Address - Country:US
Mailing Address - Phone:203-259-7070
Mailing Address - Fax:203-254-7402
Practice Address - Street 1:55 WALLS DR
Practice Address - Street 2:STE. 405
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5163
Practice Address - Country:US
Practice Address - Phone:203-259-7070
Practice Address - Fax:203-254-7402
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038854207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010038854CT02OtherBLUE CROSS/BLUE SHIELD
CT010038854CT02OtherBLUE CROSS/BLUE SHIELD
CTG35188Medicare UPIN