Provider Demographics
NPI:1164650685
Name:SHOSTED, KEVIN CLIFFORD (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CLIFFORD
Last Name:SHOSTED
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2828 W 4700 S
Mailing Address - Street 2:SUITE D
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-2154
Mailing Address - Country:US
Mailing Address - Phone:801-281-3937
Mailing Address - Fax:801-281-1430
Practice Address - Street 1:2828 W 4700 S
Practice Address - Street 2:SUITE D
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-2154
Practice Address - Country:US
Practice Address - Phone:801-281-3937
Practice Address - Fax:801-281-1430
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7385204-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist