Provider Demographics
NPI:1366200909
Name:COFFEE, KAYTON (OD)
Entity type:Individual
Prefix:
First Name:KAYTON
Middle Name:
Last Name:COFFEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-9314
Mailing Address - Country:US
Mailing Address - Phone:479-270-0806
Mailing Address - Fax:
Practice Address - Street 1:101 DAWN DR
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9314
Practice Address - Country:US
Practice Address - Phone:479-795-1411
Practice Address - Fax:479-795-1412
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2885152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program