Provider Demographics
NPI:1396763074
Name:EYE CENTERS OF LOUISVILLE,P.S.C.
Entity type:Organization
Organization Name:EYE CENTERS OF LOUISVILLE,P.S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-214-3381
Mailing Address - Street 1:1400 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1309
Mailing Address - Country:US
Mailing Address - Phone:502-214-3390
Mailing Address - Fax:502-637-1550
Practice Address - Street 1:1400 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1309
Practice Address - Country:US
Practice Address - Phone:502-214-3390
Practice Address - Fax:502-637-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300133261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50002574Medicaid
KY000000187473OtherANTHEM
KY36001071Medicaid
KY000000187473OtherANTHEM
KY36001071Medicaid