Provider Demographics
NPI:1548251333
Name:MAYES, FREDDIE MICHAEL (OD OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:FREDDIE
Middle Name:MICHAEL
Last Name:MAYES
Suffix:
Gender:M
Credentials:OD OPTOMETRIST
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 676
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42330-0676
Mailing Address - Country:US
Mailing Address - Phone:270-754-4515
Mailing Address - Fax:270-754-2547
Practice Address - Street 1:1601 WEST EVERLY BROTHERS BLVD
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:KY
Practice Address - Zip Code:42330-0676
Practice Address - Country:US
Practice Address - Phone:270-754-4515
Practice Address - Fax:270-754-2547
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY906DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000319883OtherANTHEM BLUE CROSS
KY0906OtherEYEMED
KY77009066Medicaid
T54664Medicare UPIN
KY5048640001Medicare PIN
KY0909001Medicare PIN
KYP00107375Medicare PIN