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General NPI Number Information
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NPI Number | 1548150360
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Entity Type | Individual
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Provider Name | KEVIN DAUGHERTY OD
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Gender | Male
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Dates
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Enumeration Date | 07/03/2025
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Last Update Date | 07/03/2025
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Provider Practice Location Address
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Address Line | 1307 STATE HWY K
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City | O'FALLON
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State | MO
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Zip | 63366
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Country | US
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Telephone | 636-980-2721
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Fax |
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Provider Business Mailing Address
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Address Line | 11157 E MAYWOOD CT
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City | EFFINGHAM
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State | IL
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Zip | 62401-7429
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Country | US
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Telephone | 217-821-0920
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2025023537
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License Number State | MO
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