Provider Demographics
NPI:1912113713
Name:KICKHAM, KEVIN ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROBERT
Last Name:KICKHAM
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 1:1308 E BATTLEFIELD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-890-7599
Mailing Address - Fax:417-886-6484
Practice Address - Street 1:1308 E BATTLEFIELD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-890-7599
Practice Address - Fax:417-886-6484
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00256828OtherRAILROAD MEDICARE
MO315387803Medicaid
U30760Medicare UPIN
MOP00256828OtherRAILROAD MEDICARE