Provider Demographics
NPI:1376563775
Name:FOUNTAIN, KEVIN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-1248
Mailing Address - Country:US
Mailing Address - Phone:734-439-2020
Mailing Address - Fax:734-439-2047
Practice Address - Street 1:7 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1248
Practice Address - Country:US
Practice Address - Phone:734-439-2020
Practice Address - Fax:734-439-2047
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6230060001Medicare NSC