Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | OPT 9146 | CA |
NPI | 1003879123 |
---|---|
Provider Name | Dr. Robert Kesead JR. |
First Address | Hurlburt Field, FL 32544-5613 |
Second Address | Hurlburt Field, FL 32544-5613 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2006 |
Last Update Date | 08/07/2007 |