Provider Demographics
NPI:1740440742
Name:PHELPS, JIMMIE TANTILLO (PSC)
Entity type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:TANTILLO
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 GERI LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2359
Mailing Address - Country:US
Mailing Address - Phone:859-623-4267
Mailing Address - Fax:859-623-4249
Practice Address - Street 1:205 GERI LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2359
Practice Address - Country:US
Practice Address - Phone:859-623-4267
Practice Address - Fax:859-623-4249
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY325156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY52800919Medicaid
KYOP0933OtherEYE MED