Provider Demographics
NPI:1750361176
Name:SNODGRASS, KEVIN R (OD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:SNODGRASS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1250 NW 128TH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-7432
Mailing Address - Country:US
Mailing Address - Phone:515-223-9595
Mailing Address - Fax:515-223-9792
Practice Address - Street 1:1250 NW 128TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7432
Practice Address - Country:US
Practice Address - Phone:515-223-9595
Practice Address - Fax:515-223-9792
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAIA1995152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAU39235Medicare UPIN
17676Medicare PIN