1609975614 NPI number — DR. ALICIA HERRMANN O.D.

Table of content: DR. ALICIA HERRMANN O.D. (NPI 1609975614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609975614 NPI number — DR. ALICIA HERRMANN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERRMANN
Provider First Name:
ALICIA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR
Provider Other First Name:
ALICIA
Provider Other Middle Name:
HERRMANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1609975614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 207170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-7156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-200-4393
Provider Business Mailing Address Fax Number:
636-527-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10232 WESTPORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-2148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-339-2042
Provider Business Practice Location Address Fax Number:
502-339-2044
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1266DT , 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: 161677858 . This is a "TRICARE PRIME" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 31675 . This is a "AVESIS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000313513 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 161677858 . This is a "MAILHANDLERS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 19750 . This is a "SPECTERA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4360512 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77012664 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 911299 . This is a "PASSPORT/BLOCK LOC 019488" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 448070 . This is a "HIGHMARK" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 161677858 . This is a "ITPE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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