Provider Demographics
NPI:1407156847
Name:M. DWAYNE YEAGER, OD, FAAO, A PROFESSIONAL ORGANIZATION
Entity Type:Organization
Organization Name:M. DWAYNE YEAGER, OD, FAAO, A PROFESSIONAL ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:M
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:YEAGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-325-3937
Mailing Address - Street 1:3805 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7436
Mailing Address - Country:US
Mailing Address - Phone:318-325-3937
Mailing Address - Fax:318-397-9717
Practice Address - Street 1:3805 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7436
Practice Address - Country:US
Practice Address - Phone:318-325-3937
Practice Address - Fax:318-397-9717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1020-199T335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1369004Medicaid
LAT19545Medicare UPIN
LA1369004Medicaid
LA5DQ74Medicare PIN