Provider Demographics
NPI:1619033321
Name:GRIFFITH, KEVIN JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAY
Last Name:GRIFFITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:KEEVIN
Other - Middle Name:JAY
Other - Last Name:GRIFFITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88221-0369
Mailing Address - Country:US
Mailing Address - Phone:575-885-5070
Mailing Address - Fax:
Practice Address - Street 1:101 S MESQUITE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5746
Practice Address - Country:US
Practice Address - Phone:575-885-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T75015Medicare UPIN
NM0653670001Medicare NSC