Provider Demographics
NPI:1750370730
Name:KENISON, KYLE J (OD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:J
Last Name:KENISON
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 1:855 WEST 6TH SOUTH
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647
Mailing Address - Country:US
Mailing Address - Phone:208-587-2020
Mailing Address - Fax:208-587-3349
Practice Address - Street 1:855 WEST 6TH SOUTH
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647
Practice Address - Country:US
Practice Address - Phone:208-587-2020
Practice Address - Fax:208-587-3349
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT 587152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1750370730Medicaid
ID1750370730Medicaid