Provider Demographics
NPI:1508870437
Name:KENMORE, TODD ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:ALAN
Last Name:KENMORE
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 1:513 N TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4938
Mailing Address - Country:US
Mailing Address - Phone:405-799-3030
Mailing Address - Fax:405-799-3737
Practice Address - Street 1:513 N TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4938
Practice Address - Country:US
Practice Address - Phone:405-799-3030
Practice Address - Fax:405-799-3737
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2366152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X, 332B00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019180BMedicaid
OK010814058OtherTAX ID
OK5203770001Medicare NSC
OK010814058OtherTAX ID
OK200019180BMedicaid