=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669600136
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE A. WEEDEN OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2009
-----------------------------------------------------
Last Update Date | 11/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2008 SW GAGE BLVD
-----------------------------------------------------
City | TOPEKA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66604-3340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-354-8383
-----------------------------------------------------
Fax | 785-354-8386
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 247 SE MAIN ST
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64063-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-434-5858
-----------------------------------------------------
Fax | 816-434-5845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | KS1830
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------