Provider Demographics
NPI:1801961453
Name:BOYER, KENNETH JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:BOYER
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 1:2443 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3028
Mailing Address - Country:US
Mailing Address - Phone:909-596-6756
Mailing Address - Fax:909-593-0786
Practice Address - Street 1:2443 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3028
Practice Address - Country:US
Practice Address - Phone:909-596-6756
Practice Address - Fax:909-593-0786
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8197TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081970Medicaid
CAEV359XMedicare PIN