Healthcare Provider Details

I. General information

NPI: 1578803201
Provider Name (Legal Business Name): KAYLAEN DITTMER EVANS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2013
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 ZEMKE AVE BLDG 1078
TAMPA FL
33621-5023
US

IV. Provider business mailing address

3250 ZEMKE AVE BLDG 1078
TAMPA FL
33621-5023
US

V. Phone/Fax

Practice location:
  • Phone: 813-827-9136
  • Fax:
Mailing address:
  • Phone: 813-827-9136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberGA # OPT002786
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 5032
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3271
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.0003271
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: