Provider Demographics
NPI:1982673927
Name:GURHOLT, KRISTIN J (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:J
Last Name:GURHOLT
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 1:937K CHETCO AVE 4005
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415
Mailing Address - Country:US
Mailing Address - Phone:541-469-6923
Mailing Address - Fax:541-469-6769
Practice Address - Street 1:937K CHETCO AVE 4005
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-469-6923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-4403152W00000X
CO1948152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU72196Medicare UPIN
COC449168Medicare ID - Type Unspecified