Provider Demographics
NPI:1083810063
Name:CARL W. SYDNOR
Entity Type:Organization
Organization Name:CARL W. SYDNOR
Other - Org Name:BRANDENBURG EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:W
Authorized Official - Last Name:SYDNOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-422-4241
Mailing Address - Street 1:732 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-1234
Mailing Address - Country:US
Mailing Address - Phone:270-422-4241
Mailing Address - Fax:270-422-5211
Practice Address - Street 1:732 HIGH ST
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1234
Practice Address - Country:US
Practice Address - Phone:270-422-4241
Practice Address - Fax:270-422-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1192-DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77011922Medicaid
KY4974240001Medicare NSC
KYU20797Medicare UPIN
KY77011922Medicaid