Provider Demographics
NPI:1750391579
Name:DEUGWILLO, KIMBERLY ANNE (OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANNE
Last Name:DEUGWILLO
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:901 DULANEY VALLEY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2600
Mailing Address - Country:US
Mailing Address - Phone:410-337-4500
Mailing Address - Fax:410-339-7326
Practice Address - Street 1:901 DULANEY VALLEY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2600
Practice Address - Country:US
Practice Address - Phone:410-337-4500
Practice Address - Fax:410-339-7326
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDTA2051152WL0500X
VA0618001696152WL0500X
PAOEG001814152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC022282B51Medicare PIN
MD863LR125Medicare PIN
V10729Medicare UPIN
VA016125B26Medicare PIN