Provider Demographics
NPI:1558339135
Name:HENDRIX, JOHN PERRY (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PERRY
Last Name:HENDRIX
Suffix:
Gender:M
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 100
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535
Mailing Address - Country:US
Mailing Address - Phone:304-887-2535
Mailing Address - Fax:912-681-8333
Practice Address - Street 1:730 NORTHSIDE DR E
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4766
Practice Address - Country:US
Practice Address - Phone:912-764-7352
Practice Address - Fax:912-681-8333
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV920-OD152W00000X
GAGA-OPT000856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150605001Medicaid
WV0150072000Medicaid
VA010049211Medicaid
WV9297101Medicare PIN
WVCG1608Medicare PIN
WV410040716Medicare PIN
WV0150072000Medicaid
WV9297102Medicare PIN
WV9297103Medicare PIN
WV0850311Medicare PIN
WVU71557Medicare UPIN
WV0202110001Medicare PIN
WV408540374AMedicare PIN