Provider Demographics
NPI:1285860841
Name:MYSLIWIEC, SANDY L (OD)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:L
Last Name:MYSLIWIEC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:KY
Mailing Address - Zip Code:42533-0296
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:2009-06-09
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1285860841OtherHUMANA
9356427OtherAETNA
TN4247102OtherBCBSTN/BLUECARE/TENNCARE
TNP01993204OtherRR MEDICARE
1285860841OtherMARCH VISION
5668218OtherCIGNA
TN0487990009OtherJACKSBORO GROUP MEDICARE DME PTAN
12282OtherSUPERIOR VISION
1285860841OtherAMERIGROUP
TN3941347OtherTN MEDICARE GROUP JACKSBORO
TN103I415299OtherMEDICARE PTAN
TN3942271Medicaid
TN0487990010OtherMAYNARDVILLE GROUP MEDICARE PTAN DME