Healthcare Provider Details

I. General information

NPI: 1982918181
Provider Name (Legal Business Name): MICAH JASON KINNEY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 836 BOX 2670
FPO AE
09636-9998
US

IV. Provider business mailing address

USFFC 1562 MITSCHER AVE STE 250
NORFOLK VA
23551-2487
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 757-836-5929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number2200
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2200
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: