Provider Demographics
NPI:1386601292
Name:SKINNER, KURT (OD)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:SKINNER
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 1:3133 W MARCH LN
Mailing Address - Street 2:SUITE 2020
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3133 W MARCH LN
Practice Address - Street 2:SUITE 2020
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2336
Practice Address - Country:US
Practice Address - Phone:209-957-5122
Practice Address - Fax:209-951-2348
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8861T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0088610Medicaid
CA0694800001OtherDMERC
CA0694800001OtherDMERC
CASD0088610Medicare PIN