Provider Demographics
NPI:1770635831
Name:KAISER, KENNETH LESLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LESLEY
Last Name:KAISER
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 1:215 2ND ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-0319
Mailing Address - Country:US
Mailing Address - Phone:707-444-2968
Mailing Address - Fax:707-444-2968
Practice Address - Street 1:215 2ND ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-0319
Practice Address - Country:US
Practice Address - Phone:707-444-2968
Practice Address - Fax:707-444-2968
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6259T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0040714Medicaid