Provider Demographics
NPI:1417085820
Name:AVERY, KATHLEEN GORE (OD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GORE
Last Name:AVERY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 WINGHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3600
Mailing Address - Country:US
Mailing Address - Phone:636-561-3937
Mailing Address - Fax:
Practice Address - Street 1:3013 WINGHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3600
Practice Address - Country:US
Practice Address - Phone:636-561-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2659152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU05557Medicare UPIN