Provider Demographics
NPI:1093916223
Name:CRUTCHFIELD, KENNETH GRAHAM (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GRAHAM
Last Name:CRUTCHFIELD
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 1:310 KENT ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6107
Mailing Address - Country:US
Mailing Address - Phone:573-659-7363
Mailing Address - Fax:
Practice Address - Street 1:310 KENT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6107
Practice Address - Country:US
Practice Address - Phone:573-659-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02684152W00000X
VA0601001489152W00000X
TX04962T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU52965Medicare UPIN