Provider Demographics
NPI:1235134982
Name:RIVERA - KUNZ, KATHLEEN M (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:RIVERA - KUNZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3402
Mailing Address - Country:US
Mailing Address - Phone:618-532-5531
Mailing Address - Fax:618-532-6706
Practice Address - Street 1:408 W 2ND ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3402
Practice Address - Country:US
Practice Address - Phone:618-532-5531
Practice Address - Fax:618-532-6706
Is Sole Proprietor?:No
Enumeration Date:2005-06-18
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008908 2Medicaid
IL203195Medicare PIN
IL203194Medicare PIN
IL4669520006Medicare NSC
IL410049270Medicare PIN
IL4669520002Medicare NSC
IL4669520007Medicare NSC
ILU67329Medicare UPIN
ILCK5584Medicare PIN
IL046008908 2Medicaid
IL4669520005Medicare NSC