Provider Demographics
NPI:1437257680
Name:KINKADE, BRIAN KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:KINKADE
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 1:1104 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-1032
Mailing Address - Country:US
Mailing Address - Phone:641-782-5455
Mailing Address - Fax:641-782-5590
Practice Address - Street 1:806 LAUREL ST
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-3554
Practice Address - Country:US
Practice Address - Phone:641-782-5455
Practice Address - Fax:641-782-5590
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1297374Medicaid
IA39206OtherWELLMARK
IAI16774Medicare ID - Type UnspecifiedNAS MEDICARE PART B