Provider Demographics
NPI:1457344525
Name:KEMP, WESLEY DON (OD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:DON
Last Name:KEMP
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:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0042
Mailing Address - Country:US
Mailing Address - Phone:417-777-9000
Mailing Address - Fax:417-777-9003
Practice Address - Street 1:325 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2052
Practice Address - Country:US
Practice Address - Phone:417-777-9000
Practice Address - Fax:417-777-9003
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02963152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO313115305Medicaid
MO000009697Medicare PIN
MOU19663Medicare UPIN
MO0271370001Medicare NSC