Provider Demographics
NPI:1770757791
Name:DAVID A. KYLE OD PC
Entity type:Organization
Organization Name:DAVID A. KYLE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KYLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:906-228-8808
Mailing Address - Street 1:1055 W BARAGA AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4068
Mailing Address - Country:US
Mailing Address - Phone:906-228-8808
Mailing Address - Fax:906-228-9022
Practice Address - Street 1:1055 W BARAGA AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4068
Practice Address - Country:US
Practice Address - Phone:906-228-8808
Practice Address - Fax:906-228-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003683152WC0802X, 152WP0200X, 152WS0006X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI130001809OtherWEA
MI900E265210OtherBCBS
MI94-3319568Medicaid
MI1173800001Medicare NSC
MI0E26521Medicare PIN
U43798Medicare UPIN