Provider Demographics
NPI:1649364704
Name:HAVENS LOWER, AMY LOUISE (OD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:HAVENS LOWER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:HAVENS
Other - Last Name:LOWER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 207293
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7255
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:
Practice Address - Street 1:109 S 6TH ST # A
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434
Practice Address - Country:US
Practice Address - Phone:785-742-3631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH4839152WC0802X, 152WP0200X
KS2072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHV12156Medicare UPIN
OH4206273Medicare PIN