Provider Demographics
NPI:1548150360
Name:DAUGHERTY, KEVIN (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:DAUGHERTY
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 1:11157 E MAYWOOD CT
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-7429
Mailing Address - Country:US
Mailing Address - Phone:217-821-0920
Mailing Address - Fax:
Practice Address - Street 1:1307 STATE HWY K
Practice Address - Street 2:
Practice Address - City:O'FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366
Practice Address - Country:US
Practice Address - Phone:636-980-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025023537152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist