Provider Demographics
NPI:1386818813
Name:KEVIN B WYNNE OD PLLC
Entity type:Organization
Organization Name:KEVIN B WYNNE OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:585-381-4640
Mailing Address - Street 1:56 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-2344
Mailing Address - Country:US
Mailing Address - Phone:585-381-4640
Mailing Address - Fax:
Practice Address - Street 1:56 STATE ST
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-2344
Practice Address - Country:US
Practice Address - Phone:585-381-4640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005374-1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies