Basic Information
| Provider Information | |||||||||
| NPI: | 1164402590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGEORGE | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | MARVIN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 PERIMETER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405174121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592789393 | ||||||||
| FaxNumber: | 8592780923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1431 CUMBERLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLESBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409651117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062487772 | ||||||||
| FaxNumber: | 6062480575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1298DT | KY | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77000107 | 05 | KY | MEDICAID |