Provider Demographics
NPI:1417087644
Name:ROWE, KEVIN (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:ROWE
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 1:500 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-2169
Mailing Address - Country:US
Mailing Address - Phone:928-289-4646
Mailing Address - Fax:928-289-6290
Practice Address - Street 1:500 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2169
Practice Address - Country:US
Practice Address - Phone:928-289-4646
Practice Address - Fax:928-289-6290
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1006152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ127525Medicaid
U75805Medicare UPIN
AZ127525Medicaid
AZ8ED876Medicare PIN
AZ8ED874Medicare PIN