Provider Demographics
NPI:1841606688
Name:WHELAN, KEVAN
Entity Type:Individual
Prefix:
First Name:KEVAN
Middle Name:
Last Name:WHELAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 S CAPITAL OF TEXAS HWY
Mailing Address - Street 2:STE F7
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-8118
Mailing Address - Country:US
Mailing Address - Phone:512-306-8949
Mailing Address - Fax:512-306-8625
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8832T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist