Healthcare Provider Details

I. General information

NPI: 1154374544
Provider Name (Legal Business Name): KENNETH J GARCIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 GLEN COVE DR
ROCKPORT ME
04856-4272
US

IV. Provider business mailing address

1575 WASHINGTON ST
WATERTOWN NY
13601-9367
US

V. Phone/Fax

Practice location:
  • Phone: 207-301-8000
  • Fax:
Mailing address:
  • Phone: 315-779-5060
  • Fax: 315-779-5028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number174464
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD27645
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number50663
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: