Provider Demographics
NPI:1780702258
Name:GERMUNDSEN, KEVIN JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:GERMUNDSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10088 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-4905
Mailing Address - Country:US
Mailing Address - Phone:714-962-9377
Mailing Address - Fax:714-593-1237
Practice Address - Street 1:10088 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-4905
Practice Address - Country:US
Practice Address - Phone:714-962-9377
Practice Address - Fax:714-593-1237
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8977T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02299ZOtherBLUE SHIELD OF CA
CA8977TOtherBLUE CROSS OF CA
CAZZZ02299ZOtherBLUE SHIELD OF CA
CAWOP8977BMedicare PIN