Healthcare Provider Details

I. General information

NPI: 1750391579
Provider Name (Legal Business Name): KIMBERLY ANNE DEUGWILLO OPTOMETRIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 DULANEY VALLEY RD SUITE 200
TOWSON MD
21204-2600
US

IV. Provider business mailing address

901 DULANEY VALLEY RD SUITE 200
TOWSON MD
21204-2600
US

V. Phone/Fax

Practice location:
  • Phone: 410-337-4500
  • Fax: 410-339-7326
Mailing address:
  • Phone: 410-337-4500
  • Fax: 410-339-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberTA2051
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number0618001696
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOEG001814
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: