Provider Demographics
NPI:1265550529
Name:HOLIWELL, KEVIN K (OD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:HOLIWELL
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 1:4022 NILES ST STE A
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-4630
Mailing Address - Country:US
Mailing Address - Phone:661-872-7380
Mailing Address - Fax:661-872-7251
Practice Address - Street 1:4022 NILES ST STE A
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-4630
Practice Address - Country:US
Practice Address - Phone:661-872-7380
Practice Address - Fax:661-872-7251
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 11064 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0110640Medicaid
CASD0110640Medicare ID - Type Unspecified
CACY150AMedicare PIN