Provider Demographics
NPI:1720086267
Name:PAGE, HEATHER ROSS (OD)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ROSS
Last Name:PAGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ROSS
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:22 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:TOMPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42167-7478
Mailing Address - Country:US
Mailing Address - Phone:270-487-5741
Mailing Address - Fax:270-487-9664
Practice Address - Street 1:22 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-7478
Practice Address - Country:US
Practice Address - Phone:270-487-5741
Practice Address - Fax:270-487-9664
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY03322OtherSPECTERA
KY77000933Medicaid
KY1386776169OtherMEDICARE GROUP
KY410049286OtherRAILROAD MEDICARE
KY8846OtherMEDICARE P-10
000000289047OtherBCBS
KY1720086267Medicaid
KY1386776169Medicaid
KY5940OtherDAVIS VISION
KY8846OtherMEDICARE P-10