Provider Demographics
NPI:1407847585
Name:HENNE, KEVIN L (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:HENNE
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 1:410 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3050
Mailing Address - Country:US
Mailing Address - Phone:863-293-0276
Mailing Address - Fax:863-299-3172
Practice Address - Street 1:410 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3050
Practice Address - Country:US
Practice Address - Phone:863-293-0276
Practice Address - Fax:863-299-3172
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL1655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
41000187OtherRAILROAD MEDICARE
FL0782670Medicaid
FL0782670Medicaid
FLT-85220Medicare UPIN
FL19298Medicare ID - Type Unspecified