Provider Demographics
NPI:1841300712
Name:CAUDILL, CLIFF M (OD)
Entity type:Individual
Prefix:DR
First Name:CLIFF
Middle Name:M
Last Name:CAUDILL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-9118
Mailing Address - Country:US
Mailing Address - Phone:606-218-5540
Mailing Address - Fax:606-218-5509
Practice Address - Street 1:147 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-218-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1341 DT152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77000768Medicaid
KY77000768Medicaid
KY77000768Medicaid