Healthcare Provider Details

I. General information

NPI: 1295714145
Provider Name (Legal Business Name): KRISTIN KAY MAUS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN KAY CANNON O.D.

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 10TH ST
FORT MADISON IA
52627-2831
US

IV. Provider business mailing address

619 10TH ST
FORT MADISON IA
52627-2831
US

V. Phone/Fax

Practice location:
  • Phone: 319-372-5181
  • Fax: 319-372-0865
Mailing address:
  • Phone: 319-372-5181
  • Fax: 319-372-0865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number02324
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0474155
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: