Provider Demographics
NPI:1376506543
Name:PROVINES, WAYNE (O D)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:PROVINES
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 GRAY FOX LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-2629
Mailing Address - Country:US
Mailing Address - Phone:501-985-1185
Mailing Address - Fax:
Practice Address - Street 1:314 MDG/SGO, 1090 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK AFB
Practice Address - State:AR
Practice Address - Zip Code:72099-0001
Practice Address - Country:US
Practice Address - Phone:501-987-8702
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9256152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision