Provider Demographics
NPI:1518910454
Name:DESLAURIERS, KATHY A (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:A
Last Name:DESLAURIERS
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:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-0867
Mailing Address - Country:US
Mailing Address - Phone:910-754-2020
Mailing Address - Fax:910-754-8811
Practice Address - Street 1:4830 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-1912
Practice Address - Country:US
Practice Address - Phone:910-754-2020
Practice Address - Fax:910-754-8811
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890158BMedicaid
NC09222OtherBLUE CROSS BLUE SHIELD OF NC
NC1518910454OtherRAILROAD MEDICARE
NC1518910454Medicare NSC
NC2473305Medicare ID - Type Unspecified
NC2473305Medicare PIN
NC09222OtherBLUE CROSS BLUE SHIELD OF NC