Provider Demographics
NPI:1053460394
Name:FLYNN, KEVIN MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:FLYNN
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 1:7415 STONEY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:MI
Mailing Address - Zip Code:49012-8851
Mailing Address - Country:US
Mailing Address - Phone:269-731-5665
Mailing Address - Fax:
Practice Address - Street 1:8085 N 32ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-9650
Practice Address - Country:US
Practice Address - Phone:269-629-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003815152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1205320001OtherDMERC
MI1205320001OtherDMERC
MIU69992Medicare UPIN
MI1205320001Medicare NSC