Provider Demographics
NPI:1578803201
Name:EVANS, KAYLAEN DITTMER (OD)
Entity type:Individual
Prefix:
First Name:KAYLAEN
Middle Name:DITTMER
Last Name:EVANS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51ST MEDICAL GROUP
Mailing Address - Street 2:UNIT 2060
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96278-2060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51ST MEDICAL GROUP
Practice Address - Street 2:UNIT 2060
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:US
Practice Address - Phone:334-953-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-16
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3271152W00000X
GAGA # OPT002786152W00000X
FLOPC 5032152W00000X
COOPT.0003271152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist