Provider Demographics
NPI:1134106636
Name:LIFFERTH, AUSTIN RAY (OD)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:RAY
Last Name:LIFFERTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 DUBOIS DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3212
Mailing Address - Country:US
Mailing Address - Phone:574-269-2777
Mailing Address - Fax:574-371-4697
Practice Address - Street 1:1935 BLUEGRASS AVE
Practice Address - Street 2:STE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1179
Practice Address - Country:US
Practice Address - Phone:502-895-0040
Practice Address - Fax:502-361-4488
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003391A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001147Medicaid
U99775Medicare UPIN
KY0701404Medicare ID - Type Unspecified
KY1454009Medicare PIN