Provider Demographics
NPI:1275625071
Name:PORISCH, KYLE (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:PORISCH
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 1:310 8TH AVE NW STE 503
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-2369
Mailing Address - Country:US
Mailing Address - Phone:605-225-2020
Mailing Address - Fax:605-725-2614
Practice Address - Street 1:118 3RD ST SE
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-2502
Practice Address - Country:US
Practice Address - Phone:605-352-4264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD627152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203610Medicaid
SD101267Medicare PIN