Provider Demographics
NPI:1376737320
Name:HOLBROOK, DONALD I (OD)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:I
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21937 MAIN STREET
Mailing Address - Street 2:DRW 778
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749-0778
Mailing Address - Country:US
Mailing Address - Phone:606-672-2040
Mailing Address - Fax:606-672-3937
Practice Address - Street 1:21937 MAIN STREET
Practice Address - Street 2:PO DRW 778
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749-0778
Practice Address - Country:US
Practice Address - Phone:606-672-2040
Practice Address - Fax:606-672-3937
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY902DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009025Medicaid
KY0290480001Medicare NSC
KY9216601Medicare PIN
KYT54708Medicare UPIN