Provider Demographics
NPI:1316982028
Name:ANDRUS, KYLE DEVON (OD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:DEVON
Last Name:ANDRUS
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 1:8889 JEWELLA AVE STE C&D
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2138
Mailing Address - Country:US
Mailing Address - Phone:318-686-5227
Mailing Address - Fax:318-716-3376
Practice Address - Street 1:8889 JEWELLA AVE STE C&D
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2138
Practice Address - Country:US
Practice Address - Phone:318-686-5227
Practice Address - Fax:318-716-3376
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1929-865AT152W00000X
UT1116749934152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002502007Medicaid
NVV0D206Medicare PIN
NVT78113Medicare UPIN
T78113Medicare UPIN
UT000090529Medicare PIN