Provider Demographics
NPI:1326016601
Name:PHILLIPS, CATHY L (OD)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CATHY
Other - Middle Name:PHILLIPS
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:330 W OSAGE ST
Practice Address - Street 2:
Practice Address - City:PACIFIC
Practice Address - State:MO
Practice Address - Zip Code:63069-1331
Practice Address - Country:US
Practice Address - Phone:636-271-4500
Practice Address - Fax:636-271-6940
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03068152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA5227028Medicare UPIN
MO009012148Medicare PIN