Provider Demographics
NPI:1508819244
Name:KIES, PHILIP GALE (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:GALE
Last Name:KIES
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 1:4452 EASTGATE BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-1584
Mailing Address - Country:US
Mailing Address - Phone:513-752-5700
Mailing Address - Fax:513-752-5716
Practice Address - Street 1:4452 EASTGATE BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1584
Practice Address - Country:US
Practice Address - Phone:513-752-5700
Practice Address - Fax:513-752-5716
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1251DT152W00000X
OH4331/T1024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH77902757Medicaid
OH77901981Medicaid
KY77540276Medicaid
OH77901999Medicaid
OH0947962Medicaid
OH0745713Medicare PIN
OH0745711Medicare PIN
KY77540276Medicaid
KY410044356Medicare PIN
OH410024106Medicare PIN
OHU43522Medicare UPIN
OH77902757Medicaid
KY0388402Medicare PIN
OH77901999Medicaid