Provider Demographics
NPI:1154813566
Name:ADKINS, ETHAN CORY ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:CORY ALLEN
Last Name:ADKINS
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 1:407 GEORGE KOSTAS DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3747
Mailing Address - Country:US
Mailing Address - Phone:304-752-2020
Mailing Address - Fax:
Practice Address - Street 1:407 GEORGE KOSTAS DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3747
Practice Address - Country:US
Practice Address - Phone:304-752-2020
Practice Address - Fax:304-752-5600
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2046-IOD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWVTPID008819Medicaid