MEDICARE: DR. NICHOLAS G KERRY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5414	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609903590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS G KERRY O.D.

Provider Business Mailing Address
First Line	:	115 OAK AVE
Second Line	:
City	:	KENTFIELD
State	:	CA
Zip	:	94904-1571
Country	:	US
Telephone Number	:	415-454-6012
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 SAN ANSELMO AVE
Second Line	:
City	:	SAN ANSELMO
State	:	CA
Zip	:	94960-2842
Country	:	US
Telephone Number	:	415-457-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	01/05/2009

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