Provider Demographics
NPI:1528173846
Name:KINCANNON, LEROY TAYLOR III (OD)
Entity type:Individual
Prefix:DR
First Name:LEROY
Middle Name:TAYLOR
Last Name:KINCANNON
Suffix:III
Gender:M
Credentials:OD
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Mailing Address - Street 1:3221 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1831
Mailing Address - Country:US
Mailing Address - Phone:218-260-8536
Mailing Address - Fax:218-262-3855
Practice Address - Street 1:1542 GOLF COURSE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-9603
Practice Address - Country:US
Practice Address - Phone:218-326-3433
Practice Address - Fax:218-326-3435
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist