Provider Demographics
NPI:1770553943
Name:KISSEL, KEVIN TODD (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TODD
Last Name:KISSEL
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 1789
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874-1789
Mailing Address - Country:US
Mailing Address - Phone:304-732-6322
Mailing Address - Fax:304-732-8919
Practice Address - Street 1:66 MAIN AVENUE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874-1789
Practice Address - Country:US
Practice Address - Phone:304-732-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV0945152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149996000Medicaid
WV0149996000Medicaid
WV0814043Medicare ID - Type Unspecified