Provider Demographics
NPI:1780035360
Name:KEVERN, MOLLY (OD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:KEVERN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12442 CRABAPPLE MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-4065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12182 HIGHWAY 92
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4885
Practice Address - Country:US
Practice Address - Phone:770-591-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-25
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002936152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist