Provider Demographics
NPI:1114056231
Name:LYDON, KEVIN GREELEY (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GREELEY
Last Name:LYDON
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 1:6764 MEXICO RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1505
Mailing Address - Country:US
Mailing Address - Phone:636-397-2020
Mailing Address - Fax:
Practice Address - Street 1:6764 MEXICO RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1505
Practice Address - Country:US
Practice Address - Phone:636-397-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO 2357152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1309001Medicare PIN