Provider Demographics
NPI:1285623512
Name:BRAY, RHONDA KEEN (OD)
Entity type:Individual
Prefix:DR
First Name:RHONDA
Middle Name:KEEN
Last Name:BRAY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1639 WESTPARK DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-4712
Mailing Address - Country:US
Mailing Address - Phone:270-796-6021
Mailing Address - Fax:270-796-6072
Practice Address - Street 1:1639 WESTPARK DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4712
Practice Address - Country:US
Practice Address - Phone:270-796-6021
Practice Address - Fax:270-796-6072
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1371DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77013712Medicaid
KY000000052097OtherANTHEM BC/BS
07290OtherSPECTERA VISION
5022689OtherAETNA
410038312OtherRAILROAD MEDICARE
KY77013712Medicaid
MB0371930OtherDEA CERTIFICATE
KY9996Medicare PIN
KY000000052097OtherANTHEM BC/BS