Provider Demographics
NPI:1922108950
Name:SEXTON, KYLE STEVEN (OD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:STEVEN
Last Name:SEXTON
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:PO BOX 65713
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98464-1713
Mailing Address - Country:US
Mailing Address - Phone:253-864-9353
Mailing Address - Fax:253-864-9355
Practice Address - Street 1:3500 S MERIDIAN
Practice Address - Street 2:SPACE 945
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3779
Practice Address - Country:US
Practice Address - Phone:253-864-9353
Practice Address - Fax:253-864-9355
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003991152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031151Medicaid
WA406494055OtherVSP IDENTIFICATION NUMBER