Provider Demographics
NPI:1275520942
Name:AYCOCK, JOHN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:AYCOCK
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 1:808 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-3800
Mailing Address - Country:US
Mailing Address - Phone:704-283-2179
Mailing Address - Fax:704-283-8314
Practice Address - Street 1:808 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-3800
Practice Address - Country:US
Practice Address - Phone:704-283-2179
Practice Address - Fax:704-283-8314
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890901AMedicaid
NC890901AMedicaid
NC2469344Medicare ID - Type Unspecified