Provider Demographics
NPI:1902837339
Name:EGAN, KEVIN H (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:H
Last Name:EGAN
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 1:2746 OLD US 20 W
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1364
Mailing Address - Country:US
Mailing Address - Phone:574-293-3545
Mailing Address - Fax:
Practice Address - Street 1:2746 OLD US 20 W
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1364
Practice Address - Country:US
Practice Address - Phone:574-293-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002412152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00407202OtherRAILROAD MEDICARE
T90796Medicare UPIN
229440AMedicare ID - Type Unspecified
P00407202OtherRAILROAD MEDICARE