Provider Demographics
NPI:1265089718
Name:KRAM, KYLE (OD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KRAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2204
Mailing Address - Country:US
Mailing Address - Phone:586-464-1479
Mailing Address - Fax:586-464-1480
Practice Address - Street 1:3413 TITTABAWASSEE RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9489
Practice Address - Country:US
Practice Address - Phone:989-791-1044
Practice Address - Fax:989-791-4366
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005422152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194879023Medicaid