Provider Demographics
NPI:1245246107
Name:DAUM, KENT M (OD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:M
Last Name:DAUM
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 1:251 N BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5827
Mailing Address - Country:US
Mailing Address - Phone:251-690-8894
Mailing Address - Fax:
Practice Address - Street 1:251 N BAYOU ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36603-5827
Practice Address - Country:US
Practice Address - Phone:251-690-8894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALT73-TA-200152W00000X
MA4903152W00000X
ALS-B49TA-200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00477761Medicaid
AL51527365OtherBLUE CROSS BLUE SHIELD
AL410021238OtherMEDICARE RAILROAD
AL630000013Medicaid
AL011846OtherMEDICARE GROUP PAYEE NUMBER
AL000059867Medicaid
AL51059952OtherBLUE CROSS BLUE SHIELD
ALA1716 636005396OtherVISION SERVICE PLAN
LA1586056Medicaid
AL1063439065OtherNPI GROUP PAYEE NUMBER
AL051527365Medicare ID - Type Unspecified
LA1586056Medicaid