Provider Demographics
NPI:1982918181
Name:KINNEY, MICAH JASON (OD)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:JASON
Last Name:KINNEY
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:USFFC 1562 MITSCHER AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23551-2487
Mailing Address - Country:US
Mailing Address - Phone:757-836-5929
Mailing Address - Fax:
Practice Address - Street 1:USFFC 1562 MITSCHER AVE STE 250
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23551-2487
Practice Address - Country:US
Practice Address - Phone:757-836-5929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2200152W00000X, 152WX0102X
ALT-211-TA-970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL154767Medicaid
AL511-43311OtherBCBS OF ALABAMA
AL511-43311OtherBCBS OF ALABAMA