Provider Demographics
NPI:1992232235
Name:SPIKES, KAITLIN (OD)
Entity type:Individual
Prefix:DR
First Name:KAITLIN
Middle Name:
Last Name:SPIKES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1100 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1944
Mailing Address - Country:US
Mailing Address - Phone:479-443-4301
Mailing Address - Fax:479-587-6105
Practice Address - Street 1:741 E VAN ASCHE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-442-5227
Practice Address - Fax:479-582-4952
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2784152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program