Basic Information
Provider Information | |||||||||
NPI: | 1053354571 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CECIL | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | KENDALL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CECIL | ||||||||
OtherFirstName: | J. KENDALL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | O.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3469 N MAYO TRL | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415013265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6064325800 | ||||||||
FaxNumber: | 6064372307 | ||||||||
Practice Location | |||||||||
Address1: | 3469 N MAYO TRL | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415013265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6064325800 | ||||||||
FaxNumber: | 6064372307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 08/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1043DT | KY | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 410027123 | 01 | KY | RAILROAD MEDICARE | OTHER | MC0212629 | 01 | KY | DEA NUMBER | OTHER | 77010437 | 05 | KY |   | MEDICAID | 000000176212 | 01 | KY | ANTHEM BC/BS PROVIDER NUM | OTHER | 1043DT | 01 | KY | LICENSE NUMBER | OTHER |