Provider Demographics
NPI:1093060188
Name:SKIDMORE, KEVIN ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ALLEN
Last Name:SKIDMORE
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 1:854 RIDGEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403
Mailing Address - Country:US
Mailing Address - Phone:859-986-7027
Mailing Address - Fax:859-986-4749
Practice Address - Street 1:854 RIDGEWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403
Practice Address - Country:US
Practice Address - Phone:859-986-7027
Practice Address - Fax:859-986-4749
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.6159-THER152W00000X
KY1913DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK105210Medicare PIN