Provider Demographics
NPI:1013045491
Name:BOAK, FIONA S (OD)
Entity Type:Individual
Prefix:DR
First Name:FIONA
Middle Name:S
Last Name:BOAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3706 DIANN MARIE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-3818
Mailing Address - Country:US
Mailing Address - Phone:502-326-3114
Mailing Address - Fax:502-326-9751
Practice Address - Street 1:3706 DIANN MARIE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-3818
Practice Address - Country:US
Practice Address - Phone:502-326-3114
Practice Address - Fax:502-326-9751
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1423 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001444Medicaid
KY77001444Medicaid
KY9678Medicare ID - Type Unspecified