Provider Demographics
NPI:1225029697
Name:KISH, KEVIN LANGESON (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LANGESON
Last Name:KISH
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 1:352 S MAIN ST
Mailing Address - Street 2:BOX 38
Mailing Address - City:ZUMBROTA
Mailing Address - State:MN
Mailing Address - Zip Code:55992-0038
Mailing Address - Country:US
Mailing Address - Phone:507-732-7630
Mailing Address - Fax:507-732-5401
Practice Address - Street 1:352 S MAIN ST
Practice Address - Street 2:BOX 38
Practice Address - City:ZUMBROTA
Practice Address - State:MN
Practice Address - Zip Code:55992-0038
Practice Address - Country:US
Practice Address - Phone:507-732-7630
Practice Address - Fax:507-732-5401
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN174523900Medicaid
T39768Medicare UPIN
MN410000107Medicare ID - Type Unspecified