1295867703 NPI number — WM DWAYNE SIZEMORE OD PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295867703 NPI number — WM DWAYNE SIZEMORE OD PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WM DWAYNE SIZEMORE OD PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EYE CARE CNTR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295867703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITESBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41858-7494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-633-5200
Provider Business Mailing Address Fax Number:
606-633-1500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITESBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41858-7494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-633-5200
Provider Business Practice Location Address Fax Number:
606-633-1500
Provider Enumeration Date:
03/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SIZEMORE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
DWAYNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-633-5200

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  968DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000048484 . This is a "BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1417025 . This is a "UMWA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 410009550 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77901627 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0624470001 . This is a "DMERC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3155 . This is a "CHA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: C13977 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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