Provider Demographics
NPI:1720132715
Name:MAYDEW THIBAULT OPTOMETRY LLC
Entity type:Organization
Organization Name:MAYDEW THIBAULT OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:O
Authorized Official - Last Name:MAYDEW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:620-886-3222
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:604 N WALNUT
Mailing Address - City:MEDICINE LODGE
Mailing Address - State:KS
Mailing Address - Zip Code:67104
Mailing Address - Country:US
Mailing Address - Phone:620-886-3222
Mailing Address - Fax:620-886-3541
Practice Address - Street 1:604 N WALNUT
Practice Address - Street 2:
Practice Address - City:MEDICINE LODGE
Practice Address - State:KS
Practice Address - Zip Code:67104
Practice Address - Country:US
Practice Address - Phone:620-886-3222
Practice Address - Fax:620-886-3541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS20051988BMedicaid
KS1306600002Medicare NSC
KS20051988BMedicaid