Individual
DR. KENNETH RICHARD STATSICK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2303
NC
152W00000X
Optometrist
OPC 4549
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12143984
CAQH
NC
01
—
5922830
MEDICAID PIN
NC
01
—
C374
MEDICARE PTAN
NC
Enumeration date
08/20/2010
Last updated
07/16/2025
Update your record
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