Provider Demographics
NPI:1699726497
Name:EYEDEAL EYECARE II PLLC
Entity type:Organization
Organization Name:EYEDEAL EYECARE II PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:DURANT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-877-1101
Mailing Address - Street 1:1370 W 5TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-1615
Mailing Address - Country:US
Mailing Address - Phone:606-877-1101
Mailing Address - Fax:606-878-6356
Practice Address - Street 1:1370 W 5TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-1615
Practice Address - Country:US
Practice Address - Phone:606-877-1101
Practice Address - Fax:606-878-6356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1345DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77013639Medicaid
KY1267150001OtherPALMETTO
KY000000064780OtherBCBS DURANT ID #
KY77013456Medicaid
KY000000064776OtherBCBS GROUP #
KY77903276Medicaid
KY000000202838OtherBCBS HENDY ID#
KY77903276Medicaid
KY1267150001OtherPALMETTO
KYU66756Medicare UPIN
KY77013639Medicaid
KY77013456Medicaid
KY=========OtherTAX ID #