Provider Demographics
NPI:1124034020
Name:POWELL, KIM GORDON (OD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:GORDON
Last Name:POWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1326 S COY RD
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-4140
Mailing Address - Country:US
Mailing Address - Phone:419-698-4949
Mailing Address - Fax:419-698-9948
Practice Address - Street 1:3975 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3437
Practice Address - Country:US
Practice Address - Phone:419-698-4949
Practice Address - Fax:419-698-9948
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3262 T201152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist