Provider Demographics
NPI:1790881514
Name:CALNAN-HOLT, KIMBERLY J (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:CALNAN-HOLT
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 1:2517 NE KRESKY AVE
Mailing Address - Street 2:PO BOX 1506
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2409
Mailing Address - Country:US
Mailing Address - Phone:360-784-8632
Mailing Address - Fax:360-748-3869
Practice Address - Street 1:16818 E DESMET CT
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3542
Practice Address - Country:US
Practice Address - Phone:509-456-5380
Practice Address - Fax:509-456-5381
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100200152W00000X
MTOPT-OPT-LIC-579152W00000X
WA3437152W00000X
WAOD00003437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1790881514Medicaid
ID80810904Medicaid
WAG8889165OtherMEDICARE WA
WAG8889167OtherMEDICARE WA
WA0135439OtherL & I
ID1594513OtherMEDICARE ID
WAG8889168OtherMEDICARE WA
WA410045546OtherRAILROAD MEDICARE
WAG8889169OtherMEDICARE WA
WA1019169Medicaid
WAG8889166OtherMEDICARE WA
MTM011000850OtherMEDICARE MT