Provider Demographics
NPI:1487702403
Name:MINIX, MARCUS S SR (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:S
Last Name:MINIX
Suffix:SR
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 GLYNVIEW PLAZA
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653
Mailing Address - Country:US
Mailing Address - Phone:606-886-2154
Mailing Address - Fax:
Practice Address - Street 1:212 GLYNVIEW PLAZA
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653
Practice Address - Country:US
Practice Address - Phone:606-886-2154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0407156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY52800265Medicaid
KY52904075Medicaid
KY77900702Medicaid
KYNPI1780685156OtherDR. CRUM
KYNPI1215905393OtherDR. GUSSLER
KY77007342Medicaid
KY0377360001Medicare ID - Type UnspecifiedOPTICAL
KY52800265Medicaid
KYG68549Medicare UPIN
KY77900702Medicaid
KY0243001Medicare ID - Type UnspecifiedOPTOMETRY