Provider Demographics
NPI:1770575805
Name:STALLARD, KEVIN D (OD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:STALLARD
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 1:1303 SUITE 108 US 127 SOUTH
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601
Mailing Address - Country:US
Mailing Address - Phone:502-875-3050
Mailing Address - Fax:502-226-4261
Practice Address - Street 1:1303 SUITE 108 US 127 SOUTH
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601
Practice Address - Country:US
Practice Address - Phone:502-875-3050
Practice Address - Fax:502-226-4261
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1349DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1349DTOtherOD LICENSE NUMBER
KY77013498Medicaid
KYP00293402OtherRR MEDICARE
KY000000351950OtherANTHEM BCBS
KY77013498Medicaid
KYP00293402OtherRR MEDICARE
KY0941011Medicare ID - Type Unspecified