Provider Demographics
NPI:1083337489
Name:COWELL, KODY MICHAEL
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:MICHAEL
Last Name:COWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8030
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:2800 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-1311
Practice Address - Country:US
Practice Address - Phone:805-238-7250
Practice Address - Fax:805-238-0165
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT35292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist