Provider Demographics
NPI:1164402590
Name:MCGEORGE, TODD MARVIN (OD)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:MARVIN
Last Name:MCGEORGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 PERIMETER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4121
Mailing Address - Country:US
Mailing Address - Phone:859-278-9393
Mailing Address - Fax:859-278-0923
Practice Address - Street 1:1431 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1117
Practice Address - Country:US
Practice Address - Phone:606-248-7772
Practice Address - Fax:606-248-0575
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1298DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77000107Medicaid
KY4111070001Medicare NSC
KYK132321Medicare PIN
KYU84161Medicare UPIN
KYK132320Medicare PIN
KY1873001Medicare PIN