Provider Demographics
NPI:1104883560
Name:WOLBER, KENT RANDALL (OD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:RANDALL
Last Name:WOLBER
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 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4038
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:
Practice Address - Street 1:175 SHINN LN
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6754
Practice Address - Country:US
Practice Address - Phone:573-406-5730
Practice Address - Fax:573-406-1369
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02786152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312852700Medicaid
MO261465429Medicare PIN
MOT38823Medicare UPIN
MO312852700Medicaid