Provider Demographics
NPI:1548296486
Name:BROOME, KEVIN ANDREW (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ANDREW
Last Name:BROOME
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 1:701 S RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5331
Mailing Address - Country:US
Mailing Address - Phone:386-253-5999
Mailing Address - Fax:386-253-1193
Practice Address - Street 1:701 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5331
Practice Address - Country:US
Practice Address - Phone:386-253-5999
Practice Address - Fax:386-253-1193
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3301152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620421000Medicaid
FLE2350VMedicare PIN
FLU74578Medicare UPIN