Provider Demographics
NPI:1407532542
Name:KAWAGUCHI, NEIL (OD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:
Last Name:KAWAGUCHI
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 1:11065 CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-9683
Mailing Address - Country:US
Mailing Address - Phone:509-308-1311
Mailing Address - Fax:
Practice Address - Street 1:3075 N RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1389
Practice Address - Country:US
Practice Address - Phone:406-721-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOPT-OPT-LIC-4849152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist