Provider Demographics
NPI:1942304134
Name:HIGGINBOTHAM, ELDRED KEMP (OD)
Entity Type:Individual
Prefix:
First Name:ELDRED
Middle Name:KEMP
Last Name:HIGGINBOTHAM
Suffix:
Gender:M
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 849
Mailing Address - Street 2:
Mailing Address - City:HOHENWALD
Mailing Address - State:TN
Mailing Address - Zip Code:38462-0849
Mailing Address - Country:US
Mailing Address - Phone:931-796-4669
Mailing Address - Fax:931-796-1222
Practice Address - Street 1:121 JOE AVE
Practice Address - Street 2:
Practice Address - City:HOHENWALD
Practice Address - State:TN
Practice Address - Zip Code:38462-1207
Practice Address - Country:US
Practice Address - Phone:931-796-4669
Practice Address - Fax:931-796-1222
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD 000577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T61149Medicare UPIN
TN3593691Medicare ID - Type Unspecified