Provider Demographics
NPI:1881620854
Name:KIVLIN, JAMES B (OD, TPA)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:B
Last Name:KIVLIN
Suffix:
Gender:M
Credentials:OD, TPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 SCHNEIDER AVE SE
Mailing Address - Street 2:SUITE#100
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-7005
Mailing Address - Country:US
Mailing Address - Phone:715-235-3838
Mailing Address - Fax:715-235-3846
Practice Address - Street 1:2303 SCHNEIDER AVE SE
Practice Address - Street 2:SUITE#100
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7005
Practice Address - Country:US
Practice Address - Phone:715-235-3838
Practice Address - Fax:715-235-3846
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1539-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0523040001OtherDMERC
WI38564800Medicaid
WIT62422Medicare UPIN
WI0523040001OtherDMERC
WI38564800Medicaid