Provider Demographics
NPI:1700890001
Name:TRI-STATE DOCTORS OF
Entity Type:Organization
Organization Name:TRI-STATE DOCTORS OF
Other - Org Name:KY DOCTORS OF OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBESH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-786-9021
Mailing Address - Street 1:175 E HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-2255
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:4655 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3970
Practice Address - Country:US
Practice Address - Phone:502-966-2020
Practice Address - Fax:502-966-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7179Medicare PIN
KY8829Medicare PIN
KY5509Medicare PIN
KY5502Medicare PIN
KY5501Medicare PIN
KY5500Medicare PIN
KY5505Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
KY5507Medicare PIN
KY5508Medicare PIN
KY5510Medicare PIN