Provider Demographics
NPI:1912953217
Name:WOODBURN, KEVIN DLYN (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DLYN
Last Name:WOODBURN
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 1:400 SIERRA COLLEGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5093
Mailing Address - Country:US
Mailing Address - Phone:530-272-3411
Mailing Address - Fax:530-272-3474
Practice Address - Street 1:400 SIERRA COLLEGE DR.
Practice Address - Street 2:SUITE A
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-272-3411
Practice Address - Fax:530-272-3474
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6840TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0068400Medicaid
CASD0068400Medicaid
CAZZZ86851ZMedicare PIN