Basic Information
| Provider Information | |||||||||
| NPI: | 1154374544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136019367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157795060 | ||||||||
| FaxNumber: | 3157795028 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064181326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037321330 | ||||||||
| FaxNumber: | 2037321332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 174464 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 50663 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00354316 | 05 | NY | MEDICAID |