Provider Demographics
NPI:1679555379
Name:HEVERLY, VONDA LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:VONDA
Middle Name:LEE
Last Name:HEVERLY
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 1:527 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-1410
Mailing Address - Country:US
Mailing Address - Phone:812-849-4385
Mailing Address - Fax:
Practice Address - Street 1:527 MAIN ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:IN
Practice Address - Zip Code:47446-1410
Practice Address - Country:US
Practice Address - Phone:812-849-4385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002881152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
234610AMedicare PIN
U68740Medicare UPIN