Provider Demographics
NPI:1427212216
Name:DUCKWORTH, SANDRA T (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:T
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2300
Mailing Address - Country:US
Mailing Address - Phone:931-393-6004
Mailing Address - Fax:931-393-4795
Practice Address - Street 1:926 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2300
Practice Address - Country:US
Practice Address - Phone:931-393-6004
Practice Address - Fax:931-393-4795
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002474152W00000X
TN2961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521581Medicaid
TN103I414494Medicare PIN