Provider Demographics
NPI:1528418977
Name:STOTT, KYLE ANDREW (OD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDREW
Last Name:STOTT
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 1:8445 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9280
Mailing Address - Country:US
Mailing Address - Phone:208-772-3208
Mailing Address - Fax:208-762-2574
Practice Address - Street 1:8445 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9280
Practice Address - Country:US
Practice Address - Phone:208-772-3208
Practice Address - Fax:208-762-2574
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100363152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist