Provider Demographics
NPI:1528154242
Name:MCELROY, KEVIN (OD, PA)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:MCELROY
Suffix:
Gender:M
Credentials:OD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3301
Mailing Address - Country:US
Mailing Address - Phone:208-888-5252
Mailing Address - Fax:208-884-4280
Practice Address - Street 1:50 E CARMEL DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-3301
Practice Address - Country:US
Practice Address - Phone:208-888-5252
Practice Address - Fax:208-884-4280
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP653152WC0802X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003410000Medicaid
PA721912OtherBLUE SHIELD
IDV7169OtherBLUE CROSS / TRUE BLUE
ID82304OtherBLUE SHIELD
ID82304OtherBLUE SHIELD
IDV7169OtherBLUE CROSS / TRUE BLUE
ID5603820001Medicare NSC
ID15922961Medicare PIN