Provider Demographics
NPI:1730166810
Name:CALHOUN, KENNETH S (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:CALHOUN
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 1:3213 MONITOR LN
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-1829
Mailing Address - Country:US
Mailing Address - Phone:321-693-5150
Mailing Address - Fax:863-646-0210
Practice Address - Street 1:6729 COLONNADE AVE STE 109
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-6119
Practice Address - Country:US
Practice Address - Phone:321-639-3649
Practice Address - Fax:321-639-3649
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20545CMedicare ID - Type Unspecified
U45607Medicare UPIN