Provider Demographics
NPI:1104839661
Name:GUNNERSON, KEVIN DEAN (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DEAN
Last Name:GUNNERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-3683
Mailing Address - Country:US
Mailing Address - Phone:660-263-5885
Mailing Address - Fax:660-263-2362
Practice Address - Street 1:1301 E HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-3683
Practice Address - Country:US
Practice Address - Phone:660-263-5885
Practice Address - Fax:660-263-2362
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999137663152W00000X
NE1235152W00000X
IA02126152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U83236Medicare UPIN
MO410044691Medicare PIN
MO000091242Medicare PIN