Provider Demographics
NPI:1902993652
Name:HEAD, KERRY HOWARD (OD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:HOWARD
Last Name:HEAD
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 1:205 TENNEY ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-3494
Mailing Address - Country:US
Mailing Address - Phone:309-854-0010
Mailing Address - Fax:309-854-0012
Practice Address - Street 1:205 TENNEY ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-3494
Practice Address - Country:US
Practice Address - Phone:309-854-0010
Practice Address - Fax:309-854-0010
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL047928330152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL47924OtherDAVIS VISION
IL210365Medicare ID - Type Unspecified
U66650Medicare UPIN
ILP00272430Medicare ID - Type UnspecifiedRR