Provider Demographics
NPI:1780048017
Name:AMEZCUA, KERSTIN LORRAINE (OD)
Entity type:Individual
Prefix:DR
First Name:KERSTIN
Middle Name:LORRAINE
Last Name:AMEZCUA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 BARRINGTON TRL
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-2550
Mailing Address - Country:US
Mailing Address - Phone:530-613-6541
Mailing Address - Fax:
Practice Address - Street 1:1759-1767 TANK DESTROYER BLVD
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-285-6305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60801966152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program