Provider Demographics
NPI:1982608865
Name:STULTS, KENNETH D (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:STULTS
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:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-0427
Mailing Address - Country:US
Mailing Address - Phone:641-782-7619
Mailing Address - Fax:641-782-6549
Practice Address - Street 1:1610 W TOWNLINE ST
Practice Address - Street 2:STE 115
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1064
Practice Address - Country:US
Practice Address - Phone:641-782-7619
Practice Address - Fax:641-782-6549
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02061152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA51981OtherBLUE CROSS BLUE SHIELD
IA1520261OtherOD LICENSE
IA0128975Medicaid
IA02061OtherIOWA LICENSE
IAU56526Medicare UPIN
IA02061OtherIOWA LICENSE