Provider Demographics
NPI:1992883243
Name:AVERY, DWIGHT L (OD)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:L
Last Name:AVERY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1377
Mailing Address - Country:US
Mailing Address - Phone:606-439-4010
Mailing Address - Fax:606-439-0880
Practice Address - Street 1:941 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701
Practice Address - Country:US
Practice Address - Phone:606-439-4010
Practice Address - Fax:606-439-0880
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1120OT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77011203Medicaid
KY77011203Medicaid
KY0271290001Medicare NSC
T54537Medicare UPIN