Provider Demographics
NPI:1306842695
Name:COOLBAUGH, KEVIN THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:THOMAS
Last Name:COOLBAUGH
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 1:1960 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1621
Mailing Address - Country:US
Mailing Address - Phone:540-772-7171
Mailing Address - Fax:540-774-8299
Practice Address - Street 1:1960 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1621
Practice Address - Country:US
Practice Address - Phone:540-772-7171
Practice Address - Fax:540-774-8299
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601002107152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9232800Medicaid
VA9232800Medicaid
VA410000944Medicare ID - Type Unspecified