Provider Demographics
NPI:1326043787
Name:CARL, KEVIN KYLE EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:KYLE EDWARD
Last Name:CARL
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 1:1200 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2467
Mailing Address - Country:US
Mailing Address - Phone:660-826-2642
Mailing Address - Fax:
Practice Address - Street 1:1200 WINCHESTER DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2467
Practice Address - Country:US
Practice Address - Phone:660-826-2642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02658152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312204027Medicaid
MOT81784Medicare UPIN
MOMA2061002Medicare PIN
MO000000489Medicare ID - Type Unspecified
MO312204027Medicaid
0699560001Medicare NSC
0699560002Medicare NSC