Healthcare Provider Details

I. General information

NPI: 1770757791
Provider Name (Legal Business Name): DAVID A. KYLE OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 W BARAGA AVE
MARQUETTE MI
49855-4068
US

IV. Provider business mailing address

1055 W BARAGA AVE
MARQUETTE MI
49855-4068
US

V. Phone/Fax

Practice location:
  • Phone: 906-228-8808
  • Fax: 906-228-9022
Mailing address:
  • Phone: 906-228-8808
  • Fax: 906-228-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003683
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number4901003683
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4901003683
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number4901003683
License Number StateMI

VIII. Authorized Official

Name: DR. DAVID ALAN KYLE
Title or Position: CEO
Credential: O.D.
Phone: 906-228-8808