Provider Demographics
NPI:1598752784
Name:WYNNE, KEVIN BRADLEY (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRADLEY
Last Name:WYNNE
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 1:56 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-2344
Mailing Address - Country:US
Mailing Address - Phone:585-381-4640
Mailing Address - Fax:585-381-3322
Practice Address - Street 1:56 STATE ST
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-2344
Practice Address - Country:US
Practice Address - Phone:585-381-4640
Practice Address - Fax:585-381-3322
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102002CSOtherPREFERRED CARE
14929AOtherMEDICARE GROUP #
NYPO10005374OtherBLUE CHOICE
NY7100219OtherAETNA
NY7100219OtherAETNA