Basic Information
| Provider Information | |||||||||
| NPI: | 1417958968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERR | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 BEAVER ST | ||||||||
| Address2: | |||||||||
| City: | SEWICKLEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151431501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4127418920 | ||||||||
| FaxNumber: | 4127416852 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 BEAVER ST | ||||||||
| Address2: | |||||||||
| City: | SEWICKLEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151431501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4127418920 | ||||||||
| FaxNumber: | 4127416852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG-000888 | PA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 001785566 | 05 | PA | MEDICAID |