Provider Demographics
NPI:1952494833
Name:KYNN, MICHAEL GARDNER (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GARDNER
Last Name:KYNN
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 1:9041 SOUTHSIDE BLVD
Mailing Address - Street 2:SUITE 174
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5484
Mailing Address - Country:US
Mailing Address - Phone:904-519-5855
Mailing Address - Fax:904-519-1165
Practice Address - Street 1:9041 SOUTHSIDE BLVD
Practice Address - Street 2:SUITE 174
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5484
Practice Address - Country:US
Practice Address - Phone:904-519-5855
Practice Address - Fax:904-519-1165
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3539152W00000X
LA1240395T152W00000X
PA0E7371P152W00000X
TN1148152W00000X
VA0601001915152W00000X
WA2013152W00000X
ALR134TA518152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist