Provider Demographics
NPI:1003818964
Name:REEVES, KERRY M (OD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:M
Last Name:REEVES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 GLENSFORD DR STE 105
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2365
Mailing Address - Country:US
Mailing Address - Phone:910-860-2020
Mailing Address - Fax:910-864-3719
Practice Address - Street 1:131 GLENSFORD DR STE 105
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314
Practice Address - Country:US
Practice Address - Phone:910-860-2020
Practice Address - Fax:910-864-3719
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1779152W00000X
GAOPT002735152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890922YMedicaid
NC2471704EMedicare PIN
NC890922YMedicaid