Provider Demographics
NPI:1235241381
Name:DUKES, JOHNNY RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:RAY
Last Name:DUKES
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 1:929 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-2188
Mailing Address - Country:US
Mailing Address - Phone:803-285-8433
Mailing Address - Fax:803-285-5071
Practice Address - Street 1:929 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2188
Practice Address - Country:US
Practice Address - Phone:803-285-8433
Practice Address - Fax:803-285-5071
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA1001Medicaid
SCQ240263596Medicare ID - Type Unspecified