Provider Demographics
NPI:1861707564
Name:SHIVELY, KYLE (OD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:SHIVELY
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 1:5603 AUBURN ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-2979
Mailing Address - Country:US
Mailing Address - Phone:661-489-7765
Mailing Address - Fax:661-246-3566
Practice Address - Street 1:5603 AUBURN ST UNIT A
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-2979
Practice Address - Country:US
Practice Address - Phone:661-489-7765
Practice Address - Fax:209-722-1118
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14037TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist