Provider Demographics
NPI:1871516310
Name:KENITZ, SCOTT F (OD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:F
Last Name:KENITZ
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 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1640 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027
Practice Address - Country:US
Practice Address - Phone:262-670-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38513700Medicaid
WIP00941476OtherRR MEDICARE
WIT62395Medicare UPIN
WI001467705Medicare PIN
WI462364812Medicare PIN
WI019940580Medicare PIN