Provider Demographics
NPI:1609827674
Name:SUDOL, KEVIN G (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:G
Last Name:SUDOL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1278 HOOPER AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3324
Mailing Address - Country:US
Mailing Address - Phone:732-505-0533
Mailing Address - Fax:732-505-6572
Practice Address - Street 1:341 ROUTE 4 WEST
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-489-6010
Practice Address - Fax:201-489-1885
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00528900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ401688Medicare PIN
NJU50789Medicare UPIN