Provider Demographics
NPI:1609975614
Name:HERRMANN, ALICIA (OD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:
Last Name:HERRMANN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:HERRMANN
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 207170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7156
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:10232 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2148
Practice Address - Country:US
Practice Address - Phone:502-339-2042
Practice Address - Fax:502-339-2044
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1266DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY161677858OtherTRICARE PRIME
KY31675OtherAVESIS
KY000000313513OtherANTHEM BLUE CROSS BLUE SH
KY161677858OtherMAILHANDLERS
KY19750OtherSPECTERA
KY4360512OtherAETNA
KY77012664Medicaid
KY911299OtherPASSPORT/BLOCK LOC 019488
KY448070OtherHIGHMARK
KY161677858OtherITPE