Provider Demographics
NPI:1275612525
Name:BLEVINS, MARY LYNNE (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNNE
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-1421
Mailing Address - Country:US
Mailing Address - Phone:330-875-2300
Mailing Address - Fax:330-875-4110
Practice Address - Street 1:503 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1421
Practice Address - Country:US
Practice Address - Phone:330-875-2300
Practice Address - Fax:330-875-4110
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH410046640OtherRAILROAD MEDICARE
OH0561315Medicaid
OHT48121Medicare UPIN
OH0561315Medicaid