Provider Demographics
NPI:1194809178
Name:WELLS, KEVIN W (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:W
Last Name:WELLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:4012 COMMONS DR W
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-8422
Mailing Address - Country:US
Mailing Address - Phone:580-223-5300
Mailing Address - Fax:580-223-5356
Practice Address - Street 1:4012 COMMONS DR W
Practice Address - Street 2:STE 110
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8422
Practice Address - Country:US
Practice Address - Phone:580-223-5300
Practice Address - Fax:580-223-5356
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-11-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK2263152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
V03234Medicare UPIN
OK10076330AMedicare ID - Type Unspecified
OK249728111Medicare PIN