Provider Demographics
NPI:1609903590
Name:KERRY, NICHOLAS G (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:G
Last Name:KERRY
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 1:115 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1571
Mailing Address - Country:US
Mailing Address - Phone:415-454-6012
Mailing Address - Fax:
Practice Address - Street 1:35 SAN ANSELMO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2842
Practice Address - Country:US
Practice Address - Phone:415-457-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609903590Medicaid
CAAS802YMedicare PIN
CA1308130001Medicare NSC