Provider Demographics
NPI:1326113994
Name:KOOISTRA, KEVIN DONALD (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DONALD
Last Name:KOOISTRA
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 CLIFTON AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3517
Mailing Address - Country:US
Mailing Address - Phone:973-471-1225
Mailing Address - Fax:973-472-4835
Practice Address - Street 1:1033 CLIFTON AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3517
Practice Address - Country:US
Practice Address - Phone:973-471-1225
Practice Address - Fax:973-472-4835
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00190700156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician