Provider Demographics
NPI:1154447134
Name:CONGDON, KEVIN (O D)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:CONGDON
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W1417 AUTUMN WOOD LN
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-9417
Mailing Address - Country:US
Mailing Address - Phone:715-732-9110
Mailing Address - Fax:
Practice Address - Street 1:3003 CLEVELAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143
Practice Address - Country:US
Practice Address - Phone:715-732-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2071-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38527200Medicaid
T61683Medicare UPIN