Provider Demographics
NPI:1912062654
Name:FAIRLESS, KYLE ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:ROBERT
Last Name:FAIRLESS
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 1:14600 LAKESIDE CIR
Mailing Address - Street 2:LAKESIDE MALL
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1356
Mailing Address - Country:US
Mailing Address - Phone:586-247-1000
Mailing Address - Fax:
Practice Address - Street 1:14600 LAKESIDE CIR
Practice Address - Street 2:LAKESIDE MALL
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1356
Practice Address - Country:US
Practice Address - Phone:586-247-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N26930047Medicare PIN