Provider Demographics
NPI:1124476411
Name:MAXAM, KYLE (OD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:MAXAM
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 ARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-1103
Mailing Address - Country:US
Mailing Address - Phone:937-770-1265
Mailing Address - Fax:
Practice Address - Street 1:430 ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-1103
Practice Address - Country:US
Practice Address - Phone:937-770-1265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6478152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist