Provider Demographics
NPI:1528425444
Name:DERBY CITY EYE CARE, PLLC
Entity type:Organization
Organization Name:DERBY CITY EYE CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:502-996-7450
Mailing Address - Street 1:6501 VETERANS MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-8694
Mailing Address - Country:US
Mailing Address - Phone:502-996-7450
Mailing Address - Fax:844-270-4014
Practice Address - Street 1:6501 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-8694
Practice Address - Country:US
Practice Address - Phone:502-996-7450
Practice Address - Fax:844-270-4014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1811DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100428530Medicaid