Provider Demographics
NPI:1558459305
Name:BRECKON, KIMBERLY KAY (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KAY
Last Name:BRECKON
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 1:8101 GILPIN PEAK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-4493
Mailing Address - Country:US
Mailing Address - Phone:719-640-3922
Mailing Address - Fax:
Practice Address - Street 1:7642 MCLAUGHLIN RD
Practice Address - Street 2:
Practice Address - City:FALCON
Practice Address - State:CO
Practice Address - Zip Code:80831
Practice Address - Country:US
Practice Address - Phone:719-495-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2431152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU01339Medicare UPIN