Provider Demographics
NPI:1821268392
Name:CAROL LYNN DEITZ O D INC
Entity Type:Organization
Organization Name:CAROL LYNN DEITZ O D INC
Other - Org Name:EDGEWOOD EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-341-0888
Mailing Address - Street 1:581 DUDLEY RD.
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3296
Mailing Address - Country:US
Mailing Address - Phone:859-341-0888
Mailing Address - Fax:859-341-3386
Practice Address - Street 1:581 DUDLEY RD.
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3296
Practice Address - Country:US
Practice Address - Phone:859-341-0888
Practice Address - Fax:859-341-3386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1134DT152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000049502OtherBLUE CROSS BLUE SHIELD
KY000000049502OtherBLUE CROSS BLUE SHIELD
KYT92078Medicare UPIN
KY9296901Medicare PIN