Provider Demographics
NPI:1558914150
Name:COX, KENNON (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNON
Middle Name:
Last Name:COX
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 1:102 WESTMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2970
Mailing Address - Country:US
Mailing Address - Phone:573-756-3170
Mailing Address - Fax:573-756-0173
Practice Address - Street 1:1241 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5005
Practice Address - Country:US
Practice Address - Phone:618-529-3452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist