Provider Demographics
NPI:1275539736
Name:MYSLIWIEC, KEVIN A (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
Last Name:MYSLIWIEC
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:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:KY
Mailing Address - Zip Code:42533-0306
Mailing Address - Country:US
Mailing Address - Phone:606-492-2211
Mailing Address - Fax:606-676-0873
Practice Address - Street 1:2523 JACKSBORO PIKE
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-4847
Practice Address - Country:US
Practice Address - Phone:423-566-2020
Practice Address - Fax:423-566-4245
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1843152W00000X
KY1429DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77000156Medicaid
TN3941367Medicaid
410041149OtherRAILROAD MEDICARE FOR JELLICO
TN3090877; 3154561OtherBCBSTN/BLUECARE/TENNCARE
TN3941364Medicaid
410036018OtherRAILROAD MEDICARE FOR JACKSBORO
01260522OtherAMERIGROUP
410047039OtherRAILROAD MEDICARE FOR ONEIDA
TN3090877; 3154561OtherBCBSTN/BLUECARE/TENNCARE
TN3941367Medicaid
TN3941365Medicare PIN
01260522OtherAMERIGROUP