Healthcare Provider Details

I. General information

NPI: 1588267314
Provider Name (Legal Business Name): KEVIN BIRD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 W MASON ST
GREEN BAY WI
54303-4705
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 920-490-9860
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3950-35
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: