Provider Demographics
NPI:1336344639
Name:WM.DWAYNE SIZEMORE, O.D. PSC
Entity Type:Organization
Organization Name:WM.DWAYNE SIZEMORE, O.D. PSC
Other - Org Name:EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:SIZEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-785-3274
Mailing Address - Street 1:108 HOLLY HILLS MALL
Mailing Address - Street 2:
Mailing Address - City:HINDMAN
Mailing Address - State:KY
Mailing Address - Zip Code:41822-9086
Mailing Address - Country:US
Mailing Address - Phone:606-785-3274
Mailing Address - Fax:606-785-5599
Practice Address - Street 1:108 HOLLY HILLS MALL
Practice Address - Street 2:
Practice Address - City:HINDMAN
Practice Address - State:KY
Practice Address - Zip Code:41822-9086
Practice Address - Country:US
Practice Address - Phone:606-785-3274
Practice Address - Fax:606-785-5599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY968DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77901627Medicaid
KYT54685Medicare UPIN
KY77901627Medicaid