Provider Demographics
NPI:1497902779
Name:PREMEAUX, CYNTHIA JOANNE (OD,)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:JOANNE
Last Name:PREMEAUX
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 1:6400 E MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2359
Mailing Address - Country:US
Mailing Address - Phone:614-759-9420
Mailing Address - Fax:614-759-9520
Practice Address - Street 1:6400 E MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2359
Practice Address - Country:US
Practice Address - Phone:614-759-9420
Practice Address - Fax:614-759-9520
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5816-T2730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3044182Medicaid