Provider Demographics
NPI:1417915935
Name:HAM, KRISTIN LEIGH (OD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEIGH
Last Name:HAM
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 1:2716 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-9130
Mailing Address - Country:US
Mailing Address - Phone:309-369-7486
Mailing Address - Fax:
Practice Address - Street 1:2600 ENSIGN HILL DR
Practice Address - Street 2:SUITE F
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-7836
Practice Address - Country:US
Practice Address - Phone:816-431-2202
Practice Address - Fax:816-431-2205
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009634152W00000X
KS1594152W00000X
MO2001016965152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V06385Medicare UPIN
ILV06385Medicare ID - Type Unspecified