Provider Demographics
NPI:1770633018
Name:BELCHER, MARY ANNE (OD,)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:BELCHER
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 1237
Mailing Address - Street 2:
Mailing Address - City:ELKHORN CITY
Mailing Address - State:KY
Mailing Address - Zip Code:41522-1237
Mailing Address - Country:US
Mailing Address - Phone:606-754-5775
Mailing Address - Fax:606-754-5775
Practice Address - Street 1:20 SPRING AVE
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522
Practice Address - Country:US
Practice Address - Phone:606-754-5775
Practice Address - Fax:606-754-5775
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1059DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000185534OtherANTHEM BC BS
KY410046162OtherPALMETTO/ RR MEDICARE
KY77010593Medicaid
9367802Medicare PIN
KY4640920001Medicare NSC
KY410046162OtherPALMETTO/ RR MEDICARE