Provider Demographics
NPI:1164568556
Name:HASTY, KENNETH D (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:HASTY
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 1:605 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-3210
Mailing Address - Country:US
Mailing Address - Phone:931-684-2020
Mailing Address - Fax:931-684-7000
Practice Address - Street 1:605 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3210
Practice Address - Country:US
Practice Address - Phone:931-684-2020
Practice Address - Fax:931-684-7000
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0752740001332H00000X
TN1018152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT61312Medicare UPIN
TN3596423Medicare PIN
TN0752740001Medicare NSC