Provider Demographics
NPI:1861077901
Name:WAH, KEVIN RICHARD (OD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD
Last Name:WAH
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 1:4001 CLARK PKWY
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8540
Mailing Address - Country:US
Mailing Address - Phone:214-517-5036
Mailing Address - Fax:
Practice Address - Street 1:2610 W UNIVERSITY DR STE 1240
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-1627
Practice Address - Country:US
Practice Address - Phone:940-783-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10176390200000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program